Every finding on record at Baton Rouge Health Care Center

Based on record reviews, observations, and interviews the facility failed to develop and implement a comprehensive person-centered care plan. The facility failed to:1. Ensure Resident #15's call light was within reach and covered with bright tap; and 2. Ensure Resident #71 was care planned as a safe smokerThis deficient practice had the potential to affect a current census of 94 residents. Review of the facility's policy titled, Call Light/Call Pager Systems with an effective date of date of 10/27/2014, revealed the following, in part:Policy Statement 1.1 Purpose: To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.1.5 PolicyThe call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #15Review of Resident #15's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Hemiplegia and Hemiparesis following Cerebral Vascular Accident. Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2025, indicated the resident was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 12, which indicated moderate cognitively impaired and required substantial assistance for transfers. Review of Resident #15's current Care Plan revealed the following, in part:Problem: I have a history of falls and at risk for injury related to falls. Interventions: Encouraged to use call light for assistance with transfers. On 09/29/2025 at 9:05 a.m., an observation was conducted of Resident #15's call light. Resident #15's call light was noted not in reach. Resident #15 pointed to the call light hanging on the outlet, and stated he could not reach the call light. On 09/29/2025 at 11:05 a.m., an observation was conducted with S10LPN. S10LPN confirmed the call light was not in reach of Resident #15 and should have been. 2. Review of Resident #71's Clinical Record revealed he admitted to the facility on [DATE] and had diagnoses, which included End Stage Renal Disease, Cerebral Infarction, Chronic Respiratory Failure with Hypoxia Review of Resident #71's Quarterly MDS with an ARD of 09/10/2025, indicated the resident was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 14, which indicated cognitively intact. Review of Facility's Smokers List revealed Resident #71 was not indicated as a smoker. Review of Resident #71's current Care Plan revealed no care plan indicating the resident was a smoker. On 09/29/2025 at 9:30 a.m., an observation was conducted of Resident #71 outside on the smoking patio smoking a cigarette. On 09/30/2025 at 9:47 a.m., an interview was conducted with S13CNA. She stated Resident #71 was a safe smoker. On 09/30/2025 at 9:58 a.m., an interview was conducted with S14CNA. She stated Resident #71 was a safe smoker. On 09/30/2025 at 1:07 p.m. an interview was conducted with S11CC. S11CC stated she was responsible for updating care plans. She stated a smoker should be care planned as such. She confirmed Resident #71 was not care planned as a smoker until yesterday evening when she updated his care plan. She stated he should have been care planned for being a smoker before yesterday. \

Based on interviews and record review, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to follow standing physician orders and notify the physician of blood glucose reading over 400 for 2 (#7 and #15) of 3 (#7, #12, and #15) residents reviewed for insulin administration.Review of the facility's Blood Glucose Monitoring standing orders, updated on 12/31/2024 revealed the following, in part:All admissions/readmissions with a diagnosis of Diabetes should have accuchecks. Administer Novolog/Humalog insulin SQ as indicated in the parameters below.If glucose is greater than 400 give 10 units and notify provider for additional ordersResident #7Review of Resident #7's Clinical Record revealed he was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus.Review of Resident #7's current physician orders revealed the following, in part:NovoLOG FlexPen 100 unit/mL (Insulin Aspart)-Inject as per sliding scale:401 and greater, give 10 units and notify doctor.Review of Resident #7's Medication Administration Record (MAR) revealed the following, in part:09/08/2025 at 8:00 p.m. - 409 blood glucose documented by S4LPN.Review of Resident #7's September 2025 nurses' notes revealed no documentation of notification to the doctor or nurse practitioner of elevated blood glucose levels. Resident #15Review of Resident #15's Clinical Record revealed he was admitted to the facility on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus. Review of Resident #15's current physician orders revealed the following, in part:Accucheck AC and HSNovolog Solution 100 unit/ml (Insulin Aspart)-Inject as per sliding scale:401 and greater, give 10 units and notify doctor. Review of Resident #15's Medication Administration Record (MAR) revealed the following, in part:09/08/2025 at 10:00 p.m. - 426 blood glucose documented by S4LPN;09/10/2025 at 10:00 p.m. - 447 blood glucose documented by S6LPN;09/11/2025 at 10:00 p.m. - 557 blood glucose documented by S6LPN;09/13/2025 at 4:00 p.m. - 466 blood glucose documented by S7LPN;09/18/2025 at 10:00 p.m. - 443 blood glucose documented by S6LPN;09/19/2025 at 10:00 p.m. - 428 blood glucose documented by S6LPN;09/21/2025 at 4:00 p.m. - 434 blood glucose documented by S4LPN; and 09/22/2025 at 8:00 p.m. - 486 blood glucose documented by S6LPN. Review of Resident #15's September 2025 nurses' notes revealed no documentation of notification to the doctor or nurse practitioner of elevated blood glucose levels. An interview was conducted on 09/29/2025 at 4:00 p.m. with S6LPN. She confirmed she did not notify the doctor on any of the aforementioned dates of elevated blood glucose for Resident #15 and should have. An interview was conducted on 09/30/2025 at 9:40 a.m. with S4LPN. She confirmed she did not notify the doctor on any of the aforementioned dates of elevated blood glucose for Resident #7 or Resident #15 and should have. An interview was conducted on 09/30/2025 at 1:50 p.m. with S5NP. She stated the facility had standing orders and she should be notified if a resident's blood glucose was over 400 and she would expect nurses to do so. She stated if nursing staff notified her, it should be documented in the nurse's notes. An interview was conducted on 10/01/2025 at 1:00 p.m. with S2DON. He stated the facility had standing orders and the nurse practitioner should be notified if a resident's blood glucose was over 400 and he would expect nurses to do so.

Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 2 (#15 and #99) of 24 residents reviewed during the initial pool. Review of the facility's policy titled, Call Light/Call Pager Systems with an effective date of date of 10/27/2014, revealed the following, in part:Policy Statement 1.1 Purpose: To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.1.5 PolicyThe call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #15Review of Resident #15's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Hemiplegia and Hemiparesis following Cerebral Vascular Accident. Review of Resident #15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/03/2025, indicated the resident was assessed by the facility to have a Brief Interview of Mental Status (BIMS) of 12, which indicated moderate cognitively impaired and required substantial assistance for transfers. Review of Resident #15's current Care Plan revealed the following, in part:Problem: I have a history of falls and at risk for injury related to falls. Interventions: Encouraged to use call light for assistance with transfers. On 09/29/2025 at 9:05 a.m., an observation was conducted of Resident #15's call light. Resident #15's call light was noted not in reach. Resident #15 pointed to the call light hanging on the outlet, and stated he could not reach the call light. On 09/29/2025 at 11:05 a.m., an observation was conducted with S10LPN. S10LPN confirmed the call light was not in reach of Resident #15 and should have been. Resident #99 Review of Resident #99's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Polyosteoarthritis, Visual Loss, and Pain. Review of Resident #99's quarterly MDS, with an ARD of 07/16/2025, indicated the resident was assessed by the facility to have a BIMS of 4, which indicated severe cognitively impaired and was dependent on staff for transfers. Review of Resident #99's current Care Plan revealed the following, in part: Problem: I have an activities of daily living self-care performance deficit related to Dementia Intervention: Encouraged to use call light for assistance. On 09/29/2025 at 9:42 a.m., an observation was made of Resident #99 sitting in the Geri-chair approximately 2 feet from her bed with the call light attached to the side of the resident's bed and out of reach. On 09/29/2025 at 11:10 a.m., an observation was made of Resident #99 in the Geri-chair approximately 2 feet from her bed with the call light attached to the side of the resident's bed and out of reach. On 09/29/2025 at 11:23 a.m., an observation was made of Resident #99 with S9LPN. S9LPN confirmed Resident #99's call light was attached to her bed and not in reach of Resident #99 and should have been. On 09/30/2025 at 9:47 a.m., an interview was conducted with S13CNA. S13CNA stated Resident #99 used the call light for assistance and it should be in reach at all times. On 09/30/2025 at 9:58 a.m., an interview was conducted with S14CNA. S14CNA stated resident #99 used the call light for assistance and it should be in reach at all times. On 09/30/2025 at 10:15 a.m., an interview was conducted with S15CNA. S15CNA stated Resident #99 used the call light for assistance and it should be in reach at all times. On 09/29/2025 at 3:20 p.m., an interview was conducted with S8MDS. S8MDS confirmed if a resident was care planned to use the call light for assistance, the call light should be kept within the resident's reach.

Based on record reviews and interviews, the facility failed to ensure a resident's bath was accurately documented for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for ADL's (Activities of Daily Living). Findings: Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #3's current Care Plan revealed the following, in part; Problem: I have an ADL self-care performance deficit related to Non-Traumatic Intracranial Hemorrhage with Right Sided Hemiplegia. Interventions: I am totally dependent on staff to provide a bath/shower. Review of Resident #3's Bath Flowsheet dated March 2025 to May 12, 2025 revealed the residents scheduled bath days were Monday, Wednesday, and Friday. Further review revealed Resident #3 did not have a documented bath on Monday 03/24/2025, Friday 03/28/2025, and Monday 04/28/2025. On 05/13/2025 at 1:52 p.m., an interview was conducted with S3CNA. She verified she was Resident #3's assigned CNA on 03/28/2025. She stated Resident #3 refused his bath on 03/28/2025. She reviewed Resident #3's Bath Flowsheet and verified there was no documented bath or refusal of bath for that day. She stated she should have charted he refused the bath on 03/28/2025. On 05/13/2025 at 2:43 p.m., an interview was conducted with S2CNAS. She stated she was responsible for giving Resident #3 his baths on 03/24/2025 and 04/28/2025. She stated she gave Resident #3 his baths on those days. She reviewed Resident #3's Bath Flowsheet and verified she did not document the baths on those days and should have. On 05/13/2025 at 3:47 p.m., an interview was conducted with S1DON. He reviewed Resident #3's Bath Flowsheet and verified baths were not documented on 03/24/2025, 03/28/2025, and 04/28/2025. He confirmed baths should be documented when given or refused.

43868 Based on interviews and record review, the facility failed to ensure each resident was treated with respect and dignity and cared for them in a manner that promoted enhancement of quality of life for 4 of 4 (#1, #21, #70, and #82) residents reviewed for dignity. Findings: Review of facility's policy titled, Resident Rights, dated 12/2026, revealed, in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. Be treated with respect, kindness, and dignity. Review of S8CNA's employee file revealed the following: Notice of Expected Improvement Date: 09/28/2024 Nature of Occurrence: Resident #70 reported S8CNA spoke to her in a very strong tone. Expected Improvement or Standard: S8CNA was counseled by her immediate supervisor and the administrator. S8CNA was advised improvement was expected immediately. Signed by: S8CNA and S9CNAS on 09/30/2024. Notice of Expected Improvement Date: 09/27/2024 Nature of Occurrence: S8CNA failed to treat our residents with dignity and respect. Expected Improvement or Standard: S8CNA was informed she was expected to correct this conduct immediately and a positive attitude was expected to be on display at all times while assisting and caring for residents. Signed by: S8CNA, S9CNAS and S1ADM on 09/27/2024. Notice of Expected Improvement Date: 02/25/2024 Nature of Occurrence: S8CNA was willfully disrespectful toward immediate supervisor. Expected Improvement or Standard: S8CNA was counseled on this behavior by the CNA Supervisor. Signed by: S8CNA and S9CNAS on 02/26/2024 Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS with an ARD of 09/11/2024 revealed a BIMS of 14, which indicated the resident's cognitive ability was intact. On 10/02/2024 at 11:10 a.m., an interview was conducted with Resident #1. She stated S8CNA spoke to her in a rude, condescending tone and physically handled her rough when she provided care. She stated the tone of voice S8CNA used when speaking to her felt very disrespectful and rude. Resident #21 Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #21's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS of 12, which indicated the resident's cognitive ability was moderately intact. On 10/02/2024 at 11:14 a.m., an interview was conducted with Resident #21. She stated S8CNA spoke to her in a rude, condescending tone and physically handled her rough when she provided care. She stated the tone of voice S8CNA used when speaking to her felt very disrespectful and rude. Resident #70 Review of Resident #70's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #70's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS of 11, which indicated the resident's cognitive ability was moderately intact. Review of Resident #70's Nurses Notes revealed the following: 09/29/2024 at 4:11 p.m. by S10LPN Resident #70 noted walking up and down the hallway. Resident #70 appeared to be upset. When asked, Resident #70 stated she was upset with S8CNA and was sick of her. On 10/02/2024 at 11:20 a.m., an interview was conducted with Resident #70. She stated on 09/29/2024, her toilet was not working so she received permission from S11RNS to use the bathroom in the empty room across the hall from her room. Resident #70 stated during the 2-10 p.m. shift, she walked across the hall to use the restroom. Resident #70 stated as she approached the empty room, S8CNA stated in a stern, very condescending tone of voice uh uh uh, don't you dare go in that room. Resident #70 stated she explained to S8CNA her toilet was broken and she had permission from S11RNS to use this bathroom. Resident #70 stated S8CNA responded to her in a very stern, agitated tone of voice stating, I am going to find out. Resident #70 stated she felt the tone of voice S8CNA regularly used to communicate with her was very rude and disrespectful. On 10/02/2024 at 10:54 a.m., an interview was conducted with S10LPN. She stated on 09/29/2024, Resident #70 approached her in the hallway and physically appeared to be upset. S10LPN stated Resident #70 reported she was upset with S8CNA because of the way she treats her. S10LPN confirmed she reported this information to administration and to Resident #70's family. On 10/02/2024 at 11:55 a.m., an interview was conducted with S12WC. She confirmed Resident #70 reported a broken toilet on 09/29/2024. She confirmed S11RNS gave Resident #70 permission to use the bathroom in the empty room across the hall from her room. S12WC confirmed on 09/29/2024, she saw Resident #70 coming down the hallway crying following an interaction with S8CNA. Resident #82 Review of Resident #82's Clinical Record revealed she was admitted on [DATE]. Review of Resident #82's MDS with an ARD of 08/29/2024 revealed a BIMS of 15, which indicated the resident's cognitive ability was intact. On 10/02/2024 at 12:16 p.m., an interview was conducted with Resident #82. She confirmed she was very familiar with S8CNA. Resident #82 stated S8CNA interacted and spoke to her rude, cold hearted, and unprofessional. Resident #82 stated on 09/26/2024, she asked S8CNA to apply cream to her skin because the brief had rubbed it. Resident #82 stated S8CNA refused to apply the cream to her skin and left the room. Resident #82 confirmed she reported this behavior and her concerns with the way S8CNA interacted with her to S9CNAS. On 10/02/2024 at 1:27 p.m., an interview with S9CNAS. S9CNAS confirmed all staff should treat all residents with respect and dignity at all times. S9CNAS confirmed on 09/30/2024, S8CNA was counseled and placed on suspension after Resident #82 reported S8CNA's behavior on 09/26/2024 and Resident #70 reported S8CNA's behavior on 09/29/2024. On 10/02/2024 at 2:27 p.m., an interview was conducted with S1ADM. He stated he expected all staff to treat all residents with dignity and respect at all times when providing care and services. S1ADM stated Resident #82 reported S8CNA did not interact in a positive manner and was too authoritative, and abrupt when providing care. He stated Resident #70 reported S8CNA treated her very rude and disrespectfully. He confirmed S8CNA was placed on suspension on 09/30/2024 because of the reported behavior.

Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 2 (#2 and #83) of 32 residents reviewed during the initial pool. Findings: Review of the facility's policy titled, Call Light/Call Pager Systems, with a revision date of 09/09/2022, revealed the following, in part: Policy: The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #2 Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction and Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side. Review of Resident #2's current Care Plan revealed the resident was at risk for falls. Interventions included to keep the call bell within reach when in room and answer promptly. On 09/30/2024 at 10:19 a.m., an observation was made of Resident #2 in her room. She was sitting in a Geri chair with her call light tied to the bed rail against the wall and out of reach. An interview was conducted at this time and Resident #2 confirmed she could not reach her call light. On 09/30/2024 at 10:25 a.m., an observation and concurrent interview was conducted with S7CNA. S7CNA observed Resident #2 sitting in a Geri chair in her room with the call light tied to the bed rail next to the wall. S7CNA confirmed Resident #2's call light was out of reach. On 09/30/2024 at 10:29 a.m., an interview was conducted with S4LPN. S4LPN stated Resident #2 was capable of using the call light and it should be kept in reach. Resident #83 Review of Resident #83's Clinical Record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #83's current Care Plan revealed the resident was at risk for falls. Interventions included to keep the call light within reach and to encourage the resident to call for assist. On 09/30/2024 at 10:56 a.m., an observation was made of Resident #83 in his room. He was sitting in a wheelchair on the side of the bed closest to the room door. The call light was observed tied to the bed rail and not within the resident's reach. An interview was conducted at this time and Resident #83 confirmed he could not reach his call light. On 09/30/2024 at 11:03 a.m., an observation and concurrent interview was conducted with S4LPN. S4LPN observed Resident #83 sitting in a wheelchair with the call light tied to the bed rail and not in the resident's reach. S4LPN confirmed Resident #83's call light was not within reach and should have been. On 09/30/2024 at 4:30 p.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. S2DON confirmed when residents were in their room, their call lights should be in reach.

Based on observation, interviews, and record review, the facility failed to provide privacy to residents when receiving assistance with personal care for 1 (#52) of 4 (#15, #52, #70, and #140) residents reviewed for ADL (Activities of Daily Living) care. The facility failed to ensure the privacy curtain was pulled between Resident #52 and his roommate prior to staff initiating assistance to change his soiled brief and bed linens. Findings: Review of the facility's policy titled, Dignity, with a revision date of 02/2021, revealed the following, in part: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Review of Resident #52's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Pulmonary Fibrosis and Chronic Respiratory Failure with Hypoxia. Review of Resident #52's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/19/2024 revealed the resident was always incontinent of bowel and bladder. On 10/01/2024 at 7:54 a.m., an observation revealed S5CNA providing ADL care to Resident #52. Resident #52 shared a room with one other resident, and Resident #52's bed was located closest to the door/entrance into the room. The privacy curtain was not pulled between Resident #52 and his roommate who was observed awake and sitting in a wheelchair near the foot of his bed. Resident #52 was observed in bed uncovered, revealing the resident's unclothed body with just a brief on, which was unfastened. Resident #52's soiled shirt and bed linens were observed on the floor in front of the resident's bed. During the observation, S6CNA entered Resident #52's room, and pushed his roommate out of the room in the wheelchair past Resident #52's bed. On 10/01/2024 at 8:00 a.m., an interview was conducted with S5CNA. S5CNA confirmed the aforementioned observations. S5CNA confirmed she did not pull the privacy curtain between Resident #52 and his roommate and the resident could be visualized by his roommate. S5CNA stated for the dignity and privacy of the resident she should have closed the privacy curtain between Resident #52 and his roommate. On 10/01/2024 at 10:00 a.m., an interview was conducted with S6CNA. S6CNA confirmed the aforementioned observation. S6CNA stated when she entered Resident #52's room the resident was lying in his bed in just a brief, without clothing, and could be visualized by his roommate. S6CNA stated the privacy curtain should have been pulled between Resident #52 and his roommate. On 10/01/2024 at 1:40 p.m., an interview was conducted with S3ADON. S3ADON was made aware of the above findings. S3ADON stated staff should have pulled the privacy curtain between Resident #52 and his roommate when providing ADL care. On 10/01/2024 at 1:55 p.m., an interview was conducted with S1ADM. S1ADM was made aware of the above findings. S1ADM confirmed Resident #52's privacy curtain should have been pulled during ADL care to prevent the resident from being visualized by his roommate.

Based on record reviews and interviews, the facility failed to ensure residents, who required the assistance of two staff and a mechanical lift for transfers, remained free of accident hazards for 1 (#1) of 4 (#1, #2, #3, and #R1) residents reviewed. This deficient practice resulted in an actual harm on 05/26/2024 at 7:15 a.m. when S3CNA transferred Resident #1, who required the assistance of 2 staff and a mechanical lift for transfers, from her bed to her wheelchair alone without using a mechanical lift. At 3:30 p.m., Resident #1 complained of pain rated at an 8 on a scale to 10. The resident's left leg was slightly edematous and she yelled out in pain when the leg was moved. Resident #1 was sent to the emergency room and diagnosed with a Closed Fracture of the Left Tibia and Fibula and a Proximal Right Tibial Fracture. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings Review of the facility's undated Lifting Policy revealed the following, in part: 1.5 Policy Two persons are always required for standup lifts and bed lifts. 3.0 Procedure Lifts: Red - Total bed lift 2 people. 4. All staff are responsible for using the required number of staff members for resident transfer and lifts as per the resident's personal lift assessment. Review of Resident#1's clinical records revealed she was admitted to the facility on [DATE] with diagnosis which included: Generalized Muscle Weakness, Congestive Heart Failure, and Muscle Wasting and Atrophy. Review of Resident #1's MDS, with an ARD of 04/03/2024, revealed the facility assessed her as requiring two-person assistance for transfers. Review of Resident #1's current Care Plans revealed: Problem- I am moderate risk for falls related to I need assist with transfers, weakness secondary to diagnosis of Congestive Heart Failure . Interventions- 02/18/2022- Resident's transfer status has been changed to total bed lift with red pad with 2 staff members . Review of the facility's incident report dated 05/26/2024 at 7:15 a.m. revealed: Incident type: Witnessed Fall Person Preparing Report: S5LPN Incident Description: S3CNA stated she was trying to transfer Resident #1 to wheelchair from bed, Resident #1 was in the wheelchair, stretched her legs out in front of her, and then started to slide out of the wheelchair. S3CNA stated as Resident #1 was sliding out of the wheelchair she was guiding Resident #1 to the floor. S3CNA stated Resident #1 told her she was a total lift transfer. S3CNA stated she didn't know Resident #1 was a total lift. Review of the written staff member statements dated 05/26/2024 revealed the following: Staff member: S3CNA. Staff Statement on fall that occurred on 5/26/2024: This morning at 7:15 a.m., I was getting Resident #1 up for breakfast. Since it's been awhile since I worked with her, I did not know she uses a lift to get up. I started to transfer her into her chair, but she needed to be pulled back. I went to pull her back, and she started to slide. As I was trying to pull her up, I couldn't so I guided her to the floor. Then that's when she said they use the lift on her. Afterwards I lowered the bed and got her back in it, and I let the nurse know and got the proper equipment. Signed S3CNA Staff member: S5LPN. Staff Statement on fall that occurred on 5/26/2024: S3CNA notified me Resident #1 was on the floor. S3CNA stated she was trying to transfer the resident to the wheelchair from the bed. The resident was in the wheelchair and stretched her legs out in front of her, she then started to slide out of the wheelchair. S3CNA stated that as the resident was sliding out of the wheelchair she was guided to the floor. S3CNA stated the resident told her she was a total lift transfer. S3CNA told me she didn't know Resident #1 was a total lift, and Resident #1 didn't have a lift pad in the room. I went to the resident's room and noticed that she was lying on the bed. The resident was on her back with her head pointing to the wall and her feet were on the floor with her body perpendicular on bed. I assessed the resident and no injury was noted, skin was intact. The resident complained of no pain at this time. The Resident was transferred with the lift to the wheelchair without any issues or complaints. No signs and symptoms of pain at this time. Signed S5LPN. Review of the Nurse's Notes for Resident #1 revealed the following: 05/26/2024 3:20 p.m.: Resident #1 was lying on right side in bed, moaning and complaining of pain to left leg and hip. Resident #1 stated pain was 8/10. Acetaminophen 650 mg was orally administered at approximately 3:30 p.m. Resident #1's left leg was slightly edematous, unable to move or bend leg without Resident #1 yelling out in pain. Call placed to nurse practitioner with new orders to send to emergency room for evaluation/treatment. Review of the hospital's Tibia Fibula 2 View Left x-ray report dated 05/26/2024 revealed the following: Impression: 1. Proximal left Femoral Hemiarthroplasty. Components appear well seated without evidence of proximal Femoral Periprosthetic fracture or loosening. 2. Acute traumatic fractures of the proximal Tibial and Fibular Metaphyses, displaced up to 2 cm. Review of the Nurse's Notes for Resident #1 revealed the resident returned to the facility from the hospital on 05/29/2024 at 4:59 p.m. Further review revealed the following: 05/30/2024 6:54 a.m.: Upon making rounds Resident #1 noted lying in bed left leg wrapped with ace wrap bandage. Right lower leg noted with bruising and swelling. Leg hot to touch. Resident #1 grimaced with palpation of lateral, inside right lower leg. Resident #1 refused pain meds at this time. Negative for pedal pulse. Call placed to nurse practitioner, order for doppler venous and arterial of right lower leg. 05/30/2024 12:11 p.m.: Order to send to emergency room for evaluation and treatment . Review of the hospital's Fibula 2 View Right x-ray report dated 05/30/2024 revealed the following: Impression: Impression: Osteopenia with proximal tibial fracture. Telephone interviews were unsuccessful with S3CNA on 06/18/2024 at 2:39 p.m. and 3:33 p.m., and on 06/20/2024 at 8:48 a.m. and 11:00 a.m. Telephone interviews were unsuccessful with S5LPN on 06/18/2024 at 2:45 p.m., and 3:35 p.m., and on 06/20/2024 at 10:57 a.m., and 12:15 p.m. On 06/18/2024 at 1:40 p.m., an interview was conducted with S6SUP. She stated Resident #1 required total assistance with ADLs, 2 staff member assistance with turning, and bed lift for transferring. She stated she was aware of the incident with S3CNA and Resident #1 on 05/26/2024. She stated Resident #1's injuries could have been avoided had S3CNA asked for assistance and transferred the resident using the correct lift equipment and number of staff. On 06/20/2024 at 10:15 a.m., an interview was conducted with S2DON. He stated according to the written statement, S3CNA stated on 05/26/2024, she was transferring Resident #1 alone without a lift to the chair and Resident #1 began to slide down to the floor. He stated the resident did not initially complain of pain. He stated when the resident began to complain of pain she was sent to the emergency room to be evaluated. He stated on 05/28/2024, the hospital notified the facility that Resident #1 had a fracture to her left leg. He stated S3CNA was suspended pending the completion of the investigation, and last worked on 05/26/2024. He stated he interviewed Resident #1 while she was in the hospital, and the resident told him S3CNA was transferring her from the bed to the chair alone, without using the lift and dropped her. He stated while the investigation was on going, all staff received in-service training on lifts and transfers, over bed care plans, and lift policy. He stated all staff received a pre and posttest on lift and transfers as well as what the signs on the wall care plans indicate about a resident. He stated original staff was trained starting the day of the fall on 05/26/2024 and completed in full on 06/05/2024. He stated S3CNA gave a final statement on 05/30/2024 and she then admitted to transferring Resident#1 alone without a lift and dropped her on 05/26/2024, she was terminated on 05/30/2024. He stated S3CNA should have used the bed lift and the assistance of another staff member to transfer Resident #1 and did not. On 06/20/2024 at 11:10 a.m., an interview was conducted with S7ADON. She stated she was working as the weekend supervisor on 05/26/2024. She stated S5LPN told her S3CNA reported she lowered Resident #1 to the floor while attempting to transfer her. She stated on 05/26/2024 S3CNA told her she was trying to transferring Resident #1 from her bed to the wheelchair. The CNA explained once she transferred the resident to the wheelchair, Resident #1 began to slide down and she then assisted her to the floor. She stated S3CNA admitted she did not use the lift or another staff member to assist her during the transfer. She stated S3CNA told her she thought Resident #1 was a one person assist and did not require the lift. On 06/20/2024 at 12:20 p.m., an interview was conducted with S1ADM. He confirmed Resident #1 was assessed to be a two-person mechanical bed lift for transfers. He stated on 05/26/2024 S3CNA attempted to transfer Resident #1 to her chair without the bed lift or assistance, causing injury to Resident #1. He stated S3CNA should have followed Resident #1's over bed care plan for assistance and lift transfers. The facility has implemented the following actions to correct the deficient practice: 1. Director of Nurses, Assistant Director of Nurses, and CNA Supervisor in-serviced all nursing staff on lift policy/lift status/lift equipment, and resident over bed care plans with attention to resident transfers. 2. Lift dot audit done to ensure accuracy according to Plan of care on 05/26/2024. 3. Nursing Facility Administrator viewed cameras for visual evidence. 4. Nursing Facility Administrator suspended S3CNA immediately during investigation. 5. Continued in-services to all nursing staff on lift policy/lift status/lift equipment and over bed care plans as well as abuse and neglect by Director of Nurses. 6. Director of Nurses or designee will continue to monitor lift and transfers and record on monitoring tool, interview staff during transfer and continue to in-service nursing staff three times per week, for a minimum of 5 weeks. 7. 05/30/2024 S3CNA was terminated. 8. Competition date 06/05/2024.

Based on interviews and record review, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days and indicated the duration for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #2's June 2024 Physician's Orders revealed an order written on 06/03/2024 for Temazepam 7.5 mg tablet, one tablet by mouth as needed for Insomnia at night. Further review revealed the PRN medication had no stop date or duration. Review of Resident #2's June 2024 Medication Administration Record (MAR) revealed Temazepam 7.5 mg tablet by mouth as needed for Insomnia at night was started on 06/03/2024. Further review revealed the PRN medication had no stop date or duration. On 06/20/2024 at 10:07 a.m., an interview was conducted with S2DON. He reviewed Resident #2's June 2024 MAR and Physician Orders. He confirmed Temazepam was a psychotropic medication and was ordered PRN for longer than 14 days with no stop date or duration.

Based on observations, interviews, and record review, the facility failed to maintain a safe, functional, and sanitary environment. The facility failed to ensure: 1. There was a process in place to report and track maintenance concerns and commodes were maintained for 2 (#33 and #45) of 26 (#1, #3, #4, #10, #13, #14, #15, #16, #17, #27, #33, #35, #38, #42, #43, #44, #45, #46, #50, #57, #62, #64, #66, #69, #76, and #80) residents reviewed for environment in the initial pool. 2. Bedrails were clean and sanitized for 1 (Room B) out of 9 rooms reviewed for environment in the initial pool. Findings: 1. Resident #33 Review of Resident #33's MDS with an ARD of 08/02/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact. Resident #45 Review of Resident #45's MDS with an ARD of 08/02/2023 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of the Maintenance Log from 09/21/2023 through 10/03/2023 revealed no entry related to Resident #33 and Resident #45's commode in Room A. An observation was made of the bathroom in Room A on 10/02/2023 at 9:27 a.m. There was a black ring around the base of the commode and a thick, wide area of caulk at the base of the commode. There was a brown colored liquid on the base of the commode and surrounding the base of the commode on the floor. An interview was conducted with Residents #33 and #45 on 10/02/2023 at 9:30 a.m. Resident #33 and #45 both explained they had been reporting the leaking commode to staff for about one month and it had not been fixed. An observation was made of the bathroom in Room A on 10/03/2023 at 8:22 a.m. There was a brown colored liquid on the base of the commode and surrounding the base of the commode on the floor. The caulk was caked up around the base of the toilet. An interview was conducted with S17CNA on 10/03/2023 at 9:12 a.m. She stated the process for reporting maintenance concerns was to go straight to maintenance or let the ward clerk know to page them. She stated there was not a place to document maintenance concerns. An interview was conducted with Resident #45 on 10/03/2023 at 9:16 a.m. He stated the housekeeper saw the issues with his commode daily when she cleaned. Resident #45 stated he had also reported the issues with the commode to S15MT. Resident #45 stated he reported the issues with the commode at least one month ago and it had not been fixed. He stated the staff have had to put a towel on the bathroom floor before to soak up the water. An interview was conducted with S18CNA on 10/03/2023 at 9:23 a.m. She stated there was not a process in place to report maintenance concerns. She explained reporting maintenance concerns was a word of mouth system and she usually just reported to maintenance verbally. An interview was conducted with S12HK on 10/03/2023 at 9:25 a.m. S12HK stated she had seen water around the commode in Resident #45's bathroom. S12HK stated she reported it to S14MS approximately one week ago. She stated the process to report maintenance concerns was word of mouth. An interview was conducted with S13HK on 10/03/2023 at 12:03 p.m. She stated the process for reporting maintenance concerns was to find her supervisor and maintenance and let them know. She stated there was not a process in place for the staff to document maintenance concerns. An interview was conducted with S15MT on 10/03/2023 at 9:31 a.m. He stated there had not been anything reported regarding the commode in Room A. An interview was conducted with S14MS on 10/03/2023 at 9:33 a.m. S14MS stated he was not aware of any issues with the commode in Room A. He stated on 09/21/2023, the maintenance log was implemented. He stated staff should have written any maintenance concerns on the maintenance log. He stated prior to 09/21/2023, the facility used a word of mouth system. S14MS confirmed there was no entry for Room A on the maintenance log. An observation was made of the bathroom in Room A with S14MS and S15MT on 10/03/2023 at 9:35 a.m. S14MS confirmed the toilet tank in Room A was leaking and there was a brown, liquid substance on the base of the commode and surrounding the commode. S14MS confirmed the caulk line at the base of the commode was not adequate or intact. An interview was conducted with S2FADM on 10/03/2023 at 9:00 a.m. He stated a maintenance log was recently implemented for staff to report any maintenance concerns. He stated prior to the log being implemented, maintenance concerns were reported by word of mouth. An interview was conducted with S3ADM on 10/03/2023 at 9:51 a.m. S3ADM stated he was not aware of any issues with the commode in Room A since he started working at the facility. S3ADM stated he expected all maintenance concerns be documented on the maintenance log. He confirmed the current process for reporting and resolving environment/maintenance concerns was not working. 2. An observation was conducted of Room B on 10/04/2023 at 10:28 a.m. The bed was noted to be made with the left bed rail cream in color and the right bed rail was noted with a brown substance. An interview was conducted with S12HK on 10/04/2023 at 11:39 a.m. She stated daily cleaning and deep cleaning the resident's rooms included wiping down the bedrails. She confirmed if the room was clean and the bed was made it would be ready for a new admission. An interview was conducted with S11HK on 10/04/2023 at 11:43 a.m. She stated daily cleaning and deep cleaning the resident's rooms included wiping down the bedrails. She confirmed if the room was clean and the bed was made it would be ready for a new admission. An interview was conducted with S10HK on 10/04/2023 at 12:46 p.m. She stated daily cleaning and deep cleaning the resident's rooms included wiping down the bedrails. She confirmed if the room was clean and the bed was made it would be ready for a new admission. An observation was conducted with S10HK of Room B on 10/04/2023 at 12:50 p.m. She confirmed the room was ready for a new admit. She further confirmed the right bedrail was brown and was not cleaned. S10HKstated she would expect it to be cleaned daily and prior to the room being ready for a new admission. An interview was conducted with S3ADM on 10/04/2023 at 3:07 p.m. S3ADM confirmed he would expect the bedrails to be wiped down in a deep clean and before the room was set up for a new admission. 44965

Based on interviews and record review, the facility failed to ensure grievances were reported to the grievance official for 1 (#1) of 3 (#1, #4, and #35) residents reviewed for grievances. Findings: Review of the facility's policy titled, Resident Care Grievance Policy revealed the following, in part: Policy: Grievances/complaints are to be submitted to the Administrator who is named as the Grievance Official or their designee Review of Resident #1's MDS with an ARD of 07/05/2023 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of the Facility's Grievance Log from April 2023 through September 2023 revealed no entries for Resident #1. An interview was conducted with Resident #1 on 10/02/2023 at 10:35 a.m. Resident #1 stated her pink purse became missing about two months ago. She stated she reported it to S19CNA and S20TD. An interview was conducted with S19CNA on 10/04/2023 at 11:55 a.m. She stated Resident #1 reported a missing purse to her two months ago. She stated she figured the purse got mixed with her laundry. She stated she went to the laundry but she was unable to locate the purse. She stated she did not report the missing purse to anyone. An interview was conducted with S20TD on 10/04/2023 at 1:33 p.m. She stated Resident #1 reported her pink purse missing approximately two months ago. She stated when Resident #1 reported the missing purse, she went to look in laundry because her purse sometimes got mixed with her linens. She stated the purse was not in laundry so she provided her with a new bag. She confirmed she did not report the missing purse to anyone. An interview was conducted with S21LPN on 10/04/2023 at 12:04 p.m. She stated she was unaware of Resident #1 having a missing purse. She stated missing personal belongings should have been reported to S22SW. An interview was conducted with S22SW on 10/04/2023 at 12:08 p.m. She stated Resident #1 reported a missing purse to her on 10/03/2023. She stated the staff should report missing items to her. An interview was conducted with S3ADM on 10/04/2023 at 1:15 p.m. He stated if Resident #1 reported her purse missing, the CNA should have reported the missing item to S22SW. An interview was conducted with S2FADM on 10/04/2023 at 1:22 p.m. He stated he was unaware Resident #1 reported a missing purse to S19CNA and S20TD. He stated if Resident #1 reported the items missing to a CNA and the transportation driver, they should have reported it to the S22SW.

Based on observation, interviews, and record reviews, the facility failed to ensure appropriate alternatives were attempted prior to installing bed or side rails for 1 of 1 (#10) residents reviewed for bed or side rails out of 26 residents screened for the initial pool. Findings: Review of the facility's Bed/Side Rails policy revealed, in part: Purpose: To ensure a bed is appropriate for the resident and that if bed rails are required, they are utilized, installed, and maintained properly. 1.5 Policy: Appropriate alternative methods to aid a resident in functional bed mobility must be attempted prior to installing a side or bed rail. Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Intellectual Disabilities, Lack of Coordination, and Contractures of the Right and Left Hands. Review of Resident #10's Quarterly MDS with an ARD of 07/19/2023 revealed he was unable to complete the BIMS assessment due to an inability to be interviewed. Further review of the MDS revealed Resident #10 was totally dependent on staff for all transfers and bed mobility with two plus person physical assist. Resident #10 was noted to have functional limitations in range of motion to his bilateral upper extremities (shoulder, elbow, wrist and hand). Review of Resident #10's Physicians Orders revealed, 1/4 side rails times 2 when in bed to assist with positioning due to impaired mobility secondary to diagnosis of Cerebral Palsy with a start date of 11/05/2020. Review of Resident #10's Quarterly Side Rail/ Bed Mobility/ Lift assessment dated [DATE] revealed, in part: 3b.) Was an alternative device attempted prior to use? No 13.) Does the resident have sufficient hand grasp to assist with bed mobility? No 15.) Contractures: Left Upper Extremity Review of Resident #10's Quarterly Restraint Safety Device Elimination dated 07/19/2023 revealed, in part: 2.) Alternatives to restraint use/ safety device used in the past: None C.) Indicate/ describer which alternatives have been attempted over the last quarter: None B 27.) Describe why these alternatives did not work, prompting continued need for restraint: N/A B 28.) Describe attempts to reduce restraint use over the past quarter: N/A Review of Resident #10's Nurse's Notes from 08/23/2023 to 9/06/2023 revealed the following, in part: 08/23/2023 at 10:55 a.m., S8LPN was notified by S16CNA that upon bathing Resident #10 his left arm was inside of the bed rail, S16CNA attempted to reposition Resident #10's arm, and heard a popping sound. S8LPN assessed the resident and S6MD2 ordered an x- ray of the left arm. On 10/03/2023 at 8:35 a.m., an observation was made of Resident #10 in his bed without bedrails in place. Resident #10 was lying supine on a concave mattress with a positioning wedge on his right and left sides. Contractures were noted to his bilateral hands and wrists, and he had limited range of motion to the bilateral upper extremities. Resident #10's bilateral wrists were slightly bent downward and he was unable to grasps with his hands. Resident #10 was not observed moving his upper extremities due to his limited range of motion. An interview was attempted, but due to Resident #10's cognitive impairments, it was unsuccessful. On 10/03/2023 at 12:28 p.m., an interview was conducted with S7LPN. She confirmed she completed Resident #10's Side Rail/ Bed Mobility/ Lift Assessment, and the Restraint Safety Device Elimination Assessment. She confirmed no other alternatives were attempted or used prior to installing side rails for Resident #10. On 10/03/2023 at 3:10 p.m., an interview was conducted with S2FADM. He reported on 08/23/2023, Resident #10 was lying supine with his left arm resting between the top and bottom of the left side rail at the wrist. S2FADM demonstrated how S16CNA grabbed Resident #10's arm near his left wrist and his left elbow, then pulled the arm in toward the resident's body, and out of the side rail. S2FADM then demonstrated how S16CNA twisted Resident #10's left arm across his chest, which led to the popping sound heard by S16CNA. He confirmed Resident #10's left Humerus fracture was caused when S16CNA inappropriately manipulated the residents arm during care. He confirmed he was not aware of any other interventions attempted prior to installing Resident #10's side rails.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure 1 (#4) of 5 (#1, #2, #3, #4, and #5) residents reviewed for Resident Assessment had an accurate MDS that reflected the resident's wound care status. Findings: Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus, Polyneuropathy, and Disorder of the Skin and Subcutaneous Tissue. Review of Resident #4's current Physician Orders revealed beginning on 05/21/2023, an order for DTI (Deep Tissue Injury) Right Heel: Paint with betadine three times weekly until resolved. Review of Resident #4's Quarterly MDS with an ARD of 06/07/2023 revealed the following questions and answers related to Section M - Skin Conditions: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: G. Unstageable - Deep Tissue Injury 1. Number of unstageable pressure injuries presenting as deep tissue injury - blank, which indicated Resident #4 did not have any Deep Tissue Injury Pressure Ulcers. On 08/23/2023 at 9:10 a.m., an interview was made with S3WM. She confirmed Resident #4 had a DTI to his right heel. On 08/23/2023 at 10:15 a.m., an interview was conducted with S2CC. She confirmed she completed Resident #4's MDS Assessment with an ARD of 06/07/2023. She confirmed Resident #4 had a DTI to his right heel at the time of the assessment, and it was not coded on the MDS and should have been. On 08/23/2023 at 10:27 a.m., an interview was conducted with S1IDON. She confirmed Resident #4's DTI should have been coded in Section M of the MDS with an ARD of 06/07/2023.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure: 1. A system was in place to ensure Physicians' Orders were transcribed accurately and clarified prior to implementation for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalization s; and 2. Licensed and Registered Nurses were competent to assess and document blood glucose levels prior to medication administration for 2 (#2 and #4) of 2 (#2 and #4) residents reviewed with a diagnosis of Diabetes Mellitus. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of [DATE], when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from [DATE] through [DATE] without blood glucose monitoring and was transferred to the Emergency Department on the morning of [DATE] when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on [DATE], Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on [DATE] if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on [DATE] without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from [DATE] through [DATE]. Resident #2 was found unresponsive at 7:00 a.m. on [DATE] with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on [DATE]. S15ADM and S1DON were notified of the Immediate Jeopardy on [DATE] at 3:07 p.m. The Immediate Jeopardy was removed on [DATE] at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to administer in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system and to ensure licensed and registered nurses were competent to provide quality care to meet the needs of each resident by failing to follow, reconcile, and clarify medication orders prior to administration. Administration failed to ensure an effective system was in place for: 1. Failed to obtain a physician order clarification for blood glucose monitoring for Resident #4 prior to the administration of SQ insulin injections. 2. Failed to reconcile discharge orders and obtain physician order clarification for blood glucose monitoring and adequate oral intake prior to administration of oral diabetic medications for Resident #2. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident # 4 with orders for insulin injections were discontinued on [DATE] upon readmission from hospital. Resident #4 has active orders for CBG checks effective [DATE]; ordered by MD. Resident #2 is currently not in the facility. Completion date: [DATE]. 2. Residents admitted or readmitted to the facility have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: A. On [DATE] Administrator and DON were educated by the Regional Director of Operations regarding the job duties and responsibilities associated with: a. Competencies for licensed and registered nurses on diabetic care management b. Medication reconciliation c. Clarification of med orders prior to administration Completed [DATE]. B. On [DATE] Nurses were educated in Diabetic Management which included the following: a. The 2 types of Diabetes Mellitus: i. Type I (Insulin Dependent) ii. Type Il (Non-Insulin Dependent) b. Signs and Symptoms associated with Diabetes, including: i. Hyperglycemia (increased thirst, dry mouth, increased urination, headache, lethargy, restlessness, and loss of appetite. ii. Diabetic ketoacidosis (DKA) or hyperosmolar (nonkeotic) - (high blood sugar, ketones in the urine, nausea and/or vomiting, drowsiness, weakness, short/labored/rapid respirations abdominal pain, dehydration, diminished urine, sweet or fruity odor of breath, dry and/or flushed skin, decreased awareness/senses, loss of consciousness and/or coma.) c. Hypoglycemia (blood sugar below reference ranges) - (weakness, dizziness, or faintness, restlessness, and/or muscle twitching, Tachycardia (increased heart rate), pale/cool/moist skin, excessive perspiration, irritability, blurred/impaired vision, headaches, numbness of tongue, (more severe) stupor/unconsciousness and or convulsions and (more severe) coma. d. Associated with Diabetes e. Management of Hypoglycemia f. Medication Management Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. C. On [DATE] Nurses were educated on Order Reconciliation - Order entry to be verified by (2) nurses. Unclear orders or orders without parameters must be clarified with MD/NP. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. D. On [DATE] Nurses were educated MD/NP Notification is required for all Admission/ Readmissions. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. E. Beginning on [DATE], medication regiment review will be completed on patients admitted and readmitted to the facility within 24 hours, by the Consultant Pharmacist. F. Policies have been reviewed and no changes determined to be necessary. G. All active resident records will be reviewed by consultant pharmacist, nurse practitioner or designee with end date for [DATE] H. DON and/or ADON will review new physician orders and reconciliation of hospital discharges orders to ensure staff compliance. 4. Administrator will review the implementation of the following: A. Medication regiment review will be completed by the Consultant Pharmacist on patients admitted and readmitted to the facility within 24 hours. B. Resident Diabetic Monitoring (including receiving oral medications, insulin injections, monitoring for hypoglycemia, monitoring for hyperglycemia, monitoring HS is offered and monitoring whether order for accu-checks on any resident with Diagnosis of Diabetes.) C. and for the completion and for documentation of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, then 3 times per week for 4 weeks and then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. Beginning date: [DATE], End Date: [DATE]. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Cross Reference F-684. Cross Reference F-726. Review of the facility's Policy titled, Competency of Nursing Staff revealed the following, in part: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nurses employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: b. Any gaps in education or training that may be contributing to poor outcomes. d. A method to track, assess, plan, implement and evaluate the effectiveness of training 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care f. Basic nursing skills i. Medication management 6. Facility and resident-specific competency evaluations will include: d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed to perform. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as ,d+[DATE] mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Type 2 Diabetes Mellitus. Review of the Emergency Transfer Log from [DATE] through [DATE] revealed the following for Resident #4: Transfer date: [DATE] Location of transfer: local hospital Reason for transfer: low blood sugar Review of Resident #4's emergency room History and Physical Dated [DATE] revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge Summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted from a local hospital on [DATE]. Further review revealed Resident #2 had diagnoses which included Type 2 Diabetes Mellitus. Review of the facility's Emergency Transfer Log dated [DATE] revealed the following entries for Resident #2: Location of Transfer: Local Hospital, Transfer Date: [DATE], Return to Facility Date: [DATE] Location of Transfer: Local Hospital, Transfer Date: [DATE], Return to Facility Date: blank, Reason for Transfer: Unresponsive Review of Resident #2's Emergency Department Physician Notes dated [DATE] at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's Neurology Physician Progress Note dated [DATE] revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S1DON on [DATE] at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on [DATE] if appetite improved. She stated she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from [DATE] until [DATE] at 7:00 a.m. when there was a reading of 30 mg/dL. She stated there was no system in place to check orders behind S5MRLPN. An interview was conducted with S1DON on [DATE] at 3:18 p.m. She stated she was not aware of the issues with Resident #2's Glimepiride order and blood glucose monitoring prior to this morning when Resident #2's paperwork was requested. She stated she reviewed the documentation once it was requested and realized there was a problem. An interview was conducted with S1DON and S2ADON on [DATE] at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from [DATE] through [DATE] and received insulin twice daily beginning [DATE]. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on [DATE] at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on [DATE]. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with S3MD on [DATE] at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from [DATE] through [DATE]. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. A telephone interview was conducted with S4NP on [DATE] at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on [DATE]. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with S1DON on [DATE] at 11:05 a.m. She stated there was no system in place to check behind medical records order entries and to review hospital paperwork. She stated there was no system in place to review a resident's hospital course, including history and physicals and progress notes, to identify any deficient practice and/or errors in order entry, reconciliation, and clarification. She stated she was not aware Resident #4 had any hypoglycemic complications during her hospital stay from [DATE] through [DATE]. She stated she was not aware of Resident #4 not having blood glucose monitoring ordered from [DATE] through [DATE] until surveyor brought it to her attention. An interview was conducted with S15ADM on [DATE] at 11:30 a.m. He stated he was not aware of the issues with Resident #2 and Resident #4's orders, glucose monitoring, and medication administration. He stated the facility should have had a system in place to identify these concerns with Resident #2 and Resident #4.

Based on interviews and record reviews, the facility failed to ensure Licensed and Registered Nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility nursing staff failed to ensure: 1. S5MRLPN reconciled and clarified Physician Orders upon admission and/or readmission to the facility for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalization s; and 2. S6RN, S7LPN, S8LPN, S9LPN and S14 LPN assessed and documented residents' blood glucose levels via accucheck prior to administration of antidiabetic medications for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalization s. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of [DATE], when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from [DATE] through [DATE] without blood glucose monitoring and was transferred to the Emergency Department on the morning of [DATE] when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on [DATE], Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on [DATE] if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on [DATE] without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from [DATE] through [DATE]. Resident #2 was found unresponsive at 7:00 a.m. on [DATE] with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on [DATE]. S15ADM and S1DON were notified of the Immediate Jeopardy on [DATE] at 3:07 p.m. The Immediate Jeopardy was removed on [DATE] at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to ensure licensed and registered nurses: 1. Had specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 2. The facility nursing staff failed to reconcile, transcribe, clarify, document, and implement physician orders for Resident #2 and Resident #4. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident #4 with orders for insulin injections were discontinued on [DATE] upon readmission from hospital. Resident #4 has active orders for CBG checks effective [DATE]; ordered by MD. Resident #2 is currently not in the facility. Completion date: [DATE]. 2. Residents admitted or readmitted to the facility have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: A. On [DATE] Administrator and DON were educated by the Regional Director of Operations regarding the job duties and responsibilities associated with: a. Competencies for licensed and registered nurses on diabetic care management. b. Medication reconciliation c. Clarification of med orders prior to administration Completed [DATE]. B. On [DATE] Nurses were educated in Diabetic Management which included the following: a. The 2 types of Diabetes Mellitus: i. Type I (Insulin Dependent) ii. Type Il (Non-Insulin Dependent) b. Signs and Symptoms associated with Diabetes, including: Hyperglycemia (increased thirst, dry mouth, increased urination, headache, lethargy, restlessness, and loss of appetite. ii. Diabetic ketoacidosis (DKA) or hyperosmolar (nonkeotic) - (high blood sugar, ketones in the urine, nausea and/or vomiting, drowsiness, weakness, short/labored/rapid respirations abdominal pain, dehydration, diminished urine, sweet or fruity odor of breath, dry and/or flushed skin, decreased awareness/senses, loss of consciousness and/or coma.) c. Hypoglycemia (blood sugar below reference ranges) - (weakness, dizziness, or faintness, restlessness, and/or muscle twitching, Tachycardia (increased heart rate), pale/cool/moist skin, excessive perspiration, irritability, blurred/impaired vision, headaches, numbness of tongue, (more severe) stupor/unconsciousness and or convulsions and (more severe) coma. d. Complications Associated with Diabetes e. Management of Hypoglycemia f. Medication Management B. On [DATE] Nurses were educated in Diabetic Management. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. C. On [DATE] Nurses were educated on Order Reconciliation - Order entry to be verified by (2) nurses. Unclear orders or orders without parameters must be clarified with MD/NP. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. D. On [DATE] Nurses were educated MD/NP Notification is required for all Admission / Readmissions. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. E. Beginning on [DATE], medication regiment review will be completed on patients admitted and readmitted to the facility within 24 hours, by the Consultant Pharmacist. F. On [DATE] Pre-Test and Post-Test (including but not limited to: Diabetes defined, symptoms associated with diabetes, 2 types of diabetes, glucose monitoring, insulin administration and medications that can be utilized to manage diabetes mellitus) completed by licensed and registered nurses and given by DON; completed [DATE]. Licensed and Registered nurses on leave and/or agency staff will be educated upon the next scheduled shift. G. Policies have been reviewed and no changes were determined to be necessary. H. All active resident records will be reviewed by consultant pharmacist, nurse practitioner or designee with end date for [DATE]. I. DON and/or ADON will review execution of competencies of staff in regarding the reconciliation, transcription, clarification, documentation and implementation of physician orders including the implementation of blood glucose monitoring for residents on antidiabetic medications. 4. Administrator will review the implementation of the following: A. Medication regiment review will be completed by the Consultant Pharmacist on patients admitted and readmitted to the facility within 24 hours. B. Resident Diabetic Monitoring (including receiving oral medications, insulin injections, monitoring for hypoglycemia, monitoring for hyperglycemia, monitoring HS is offered and monitoring whether order for accuchecks on any resident with Diagnosis of Diabetes.) C. and for the completion and for documentation of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, then 3 times per week for 4 weeks and then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will review the QA minutes for completion and compliance. Begin date: [DATE], End date: [DATE]. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Cross Reference F-684. Review of the facility's Policy titled, Competency of Nursing Staff revealed the following, in part: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nurses employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: b. Any gaps in education or training that may be contributing to poor outcomes. d. A method to track, assess, plan, implement and evaluate the effectiveness of training 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care f. Basic nursing skills i. Medication management 6. Facility and resident-specific competency evaluations will include: d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed to perform. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as ,d+[DATE] mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #4's Physician Orders dated [DATE] revealed orders on [DATE] for Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100unit/ml inject 42 units SQ daily in a.m. and 32 units SQ daily in p.m. related to Type II Diabetes Mellitus. The medication was started on [DATE]. Further review revealed no order for blood glucose monitoring. Review of the Insulin Mix ,d+[DATE] Package Insert/Product Label revealed the following, in part: Generic Name: Insulin Aspart Indications and Usage: - Novolog Mix ,d+[DATE] is a mixture of insulin aspart protamine and insulin aspart indicated to improve glycemic control in adult patients with diabetes mellitus. Dosage and Administration: Important Preparation and Administration Instructions: - Always check insulin labels before administration Dosage Recommendations: - Individualize the dosage of Insulin Mix ,d+[DATE] based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. - Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness - During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen: - Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia or hyperglycemia. Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. Hypoglycemia: - Hypoglycemia is the most common adverse reaction of all insulins, including Novolog Mix ,d+[DATE]. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death. Review of Resident #4's MAR dated [DATE] revealed Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100 unit/mL inject 42 units SQ in a.m. was started on [DATE]. The medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN Further review of the [DATE] MAR revealed Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100 unit/mL inject 32 units SQ in p.m. was started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at p.m. medication pass by S14LPN [DATE] at p.m. medication pass by S6RN There was no documentation of blood glucose monitoring on the [DATE] MAR. Review of Resident #4's Vital Sign History from [DATE] through [DATE] revealed no documentation of blood glucose monitoring. Review of the Emergency Transfer Log from [DATE] through [DATE] revealed the following for Resident #4: Transfer date: [DATE] Location of transfer: Local Hospital Reason for transfer: Low Blood Sugar Review of Resident #4's emergency room History and Physical Dated [DATE] revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge Summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . An interview was conducted with S5MRLPN on [DATE] at 11:25 a.m. She stated she was responsible for reconciling Physician Orders on admission and readmission. She stated Resident #4 was admitted to the facility on [DATE] with hospital discharge orders for twice daily Insulin Aspart Prot & Aspart ,d+[DATE] 42 units in the a.m. and 32 units in the p.m. She stated the discharge orders did not specify an order to obtain blood glucose monitoring. She confirmed a resident that received insulin should receive blood glucose monitoring. She confirmed she did not contact the physician to clarify the order. She confirmed she implemented the insulin orders without blood glucose monitoring for Resident #4. An interview was conducted with S6RN on [DATE] at 1:01 p.m. She confirmed Resident #4 received Insulin Aspart Prot & Aspart ,d+[DATE] insulin while in her care. She reported, on [DATE], Resident #4 was found to have a low blood glucose level. She stated she had to administer Glucagon due to the residents' blood glucose continuing to decline. She confirmed Resident #4 was transferred to the hospital due to low blood glucose. She stated insulin should not be given without first checking a blood glucose level. She stated she checked Resident #4's blood glucose before giving her insulin but did not document it. She confirmed there were no documented blood glucose values for Resident #4 between [DATE] and [DATE] when she went to the hospital and there should have been. An interview was conducted with S1DON and S2ADON on [DATE] at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from [DATE] through [DATE]. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on [DATE] at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from [DATE] through [DATE]. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed Resident #2 had diagnoses which included Type 2 Diabetes Mellitus with Hyperglycemia Review of Resident #2's Hospital Discharge Physician Orders dated [DATE] revealed the following, in part: Change how you take the following medications: Glimepiride (Amaryl) Prescribed Medication List: Glimepiride 2 mg tablet. Start taking on [DATE]. Take one tablet by mouth in the morning and one tablet before bedtime. Hold until PO intake improves. Review of Resident #2's Physician Orders dated [DATE] revealed the resident was prescribed accuchecks BID starting [DATE] through the discontinue date of [DATE]. Resident #2 was restarted on Glimepiride 2 mg PO BID on [DATE]. Further review revealed Accuchecks were not reordered and there were no instructions to hold Glimepiride until PO intake improved. Review of the Glimepiride tablet Package Insert/Product Label revealed the following, in part: Description: Glimepiride is an oral blood-glucose-lowering drug of the sulfonylurea class. Precautions: - General: - Hypoglycemia: All sulfonylurea drugs are capable of producing severe hypoglycemia. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. Debilitated or malnourished patients, and those with adrenal, pituitary, or hepatic insufficiency are particularly susceptible to the hypoglycemic action of glucose-lowering drugs. Hypoglycemia is more likely to occur when caloric intake is deficient . Information for Patients: - Patients should be informed of the potential risks and advantages of AMARYL and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose. The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Laboratory Tests Fasting blood glucose should be monitored periodically to determine therapeutic response. Geriatric Use: - Elderly patients are particularly susceptible to hypoglycemic action of glucose-lowering drugs. In elderly, debilitated, or malnourished patients, or in patients with renal and hepatic insufficiency, the initial dosing, dose increments, and maintenance dosage should be conservative based upon blood glucose levels prior to and after initiation of treatment to avoid hypoglycemic reactions. Review of Resident #2's MAR dated [DATE] revealed Glimepiride Tablet 2 mg BID was ordered on [DATE] and started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S7LPN [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S8LPN [DATE] at a.m. medication pass by S9LPN [DATE] at p.m. medication pass by S8LPN There was no documentation of blood glucose monitoring on the above dates. Review of Resident #2's Vital Sign Record Dated [DATE] through [DATE] revealed the following Blood Glucose entry: [DATE] at 7:00 a.m. - 30 mg/dL by S9LPN Further review revealed no other entry between [DATE] through [DATE]. Review of Resident #2's Emergency Department Physician Notes dated [DATE] at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's ICU Physician Progress Note dated [DATE] revealed the following, in part: Assessment and Plan: Hypoglycemic Coma: Possibly due to Glimepiride and/or poor oral intake. Seizures: Likely due to Hypoglycemia. Being treated with Levetiracetam, Valproic Acid, Propofol, and Lacosamide. MRI indicates poor prognosis. Respiratory failure: Due to above. Review of Resident #2's Neurology Physician Progress Note dated [DATE] revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S8LPN on [DATE] at 2:16 p.m. She stated she worked the 2:00 p.m. to 10:00 p.m. shift on Resident #2's hallway. She stated Resident #2 never received blood glucose monitoring on her shift. She confirmed she administered Glimepiride to Resident #2 on the evening of [DATE]. She stated she was unaware Resident #2 did not eat her supper on [DATE]. She stated she was unaware Resident #2's Glimepiride should have been held until her intake improved. An interview was conducted with S9LPN on [DATE] at 9:42 a.m. She confirmed she sent Resident #2 to the hospital on the morning of [DATE]. She stated Resident #2's blood glucose level was 30 mg/dL and Resident #2 did not respond to any stimuli. She reviewed Resident #2's Medical Record and confirmed Resident #2 did not have an order for blood glucose monitoring and did not have blood glucose levels documented until [DATE] at 7:00 a.m. when it was 30 mg/dL. She confirmed on [DATE], Resident #2 began receiving Glimepiride 2 mg twice daily. She stated Resident #2's appetite was very poor. She stated Resident #2's appetite had decreased since her return from the hospital on [DATE]. She stated she was not aware Resident #2's Glimepiride should have been held until her appetite improved. She stated if she had known, she would have held Resident #2's Glimepiride and notified the physician. An interview was conducted with S5MRLPN on [DATE] at 11:40 a.m. She stated she reconciled Resident #2's physician orders per the discharge orders received from a local hospital on [DATE]. She confirmed prior to the resident being hospitalized , she had an order for blood glucose monitoring, but the discharge orders dated [DATE] did not list to obtain blood glucose monitoring. She stated since the new orders did not list blood glucose monitoring, she discontinued them. She stated she should have contacted Resident #2's physician to see if blood glucose monitoring should have been continued for Resident #2. She stated she entered the order for Glimepiride 2 mg twice daily on [DATE] to begin on [DATE]. She confirmed she did not add to hold the medication until Resident #2's appetite improved. She stated she should have reviewed Resident #2's meal intake and contacted Resident #2's physician to obtain a clarification to the Glimepiride order. An interview was conducted with S1DON on [DATE] at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on [DATE] if appetite improved. She stated that was subjective and she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from [DATE] until [DATE] at 7:00 a.m. when there was a reading of 30 mg/dL. An interview was conducted with S3MD on [DATE] at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on [DATE]. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. A telephone interview was conducted with S4NP on [DATE] at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on [DATE]. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with Medical Records at a local hospital on [DATE] at 4:58 p.m. She stated Resident #2 expired on [DATE].

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1. S5MRLPN reconciled and clarified Physician Orders upon admission and/or readmission to the facility for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalization s; and 2. S6RN, S7LPN, S8LPN, S9LPN and S14 LPN assessed and documented residents' blood glucose levels via accucheck prior to administering antidiabetic medications for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalization s. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of [DATE], when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from [DATE] through [DATE] without blood glucose monitoring and was transferred to the Emergency Department on the morning of [DATE] when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on [DATE], Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on [DATE] if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on [DATE] without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from [DATE] through [DATE]. Resident #2 was found unresponsive at 7:00 a.m. on [DATE] with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on [DATE]. S15ADM and S1DON were notified of the Immediate Jeopardy on [DATE] at 3:07 p.m. The Immediate Jeopardy was removed on [DATE] at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to follow, reconcile, and clarify physician orders. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident # 2 is currently not in the facility. The orders for insulin injections for Resident #4 were discontinued effective [DATE], upon readmission from the hospital. Resident #4 has active orders for CBG checks since [DATE], ordered by MD. Completion Date: [DATE]. Orders for monitoring Resident #4 for signs and symptoms of Hypoglycemia and Hyperglycemia were ordered by physician on [DATE]. Consultant Pharmacist completed a medication regimen review for Resident #4 on [DATE] with no new noted recommendations. Completion: [DATE] Nurse Practitioner visited Resident #4 on [DATE], progress notes include a review of current medications with no new orders to note. Completion Date: [DATE] Hgb A1C = 5.9% [DATE]. Completion: [DATE]. 2. New admissions and any residents readmitted to the facility have the potential to be affected by the alleged deficient practice. Facility DON and Administrator have conducted a review of all Residents with a diagnosis of Diabetes Mellitus to determine the following: Whether or not the resident is receiving an oral or injectable medication for Diabetes, Monitoring of CBGs have been ordered, Monitoring for signs and symptoms are in place for Hypoglycemia and Hyperglycemia have been ordered, Documentation of providing HS snacks is noted, and Whether or not resident is receiving an accucheck; if they do not have an accucheck ordered MD notified for recommendations. Completion: [DATE] On [DATE] Education for active nursing staff occurred on Diabetic Management by facility Director of Nurses. Completion: [DATE] On [DATE] Education for active nursing staff occurred on facility policy regarding medication reconciliation by Director of Nurses: Order entry is to be verified by 2 nurses. Any unclear orders or orders without parameters must be clarified with resident NP and/or MD. Completion: [DATE]. On [DATE] education for active nursing staff was completed regarding MD/NP notification of all admissions and readmissions by Director of Nurses. Completed: [DATE] Active Facility staff will be in-serviced on the Medication Regimen Review process for all admissions and readmissions. Medication orders and resident face sheets must be shared with the consultant pharmacist within 24 hours of admission or readmission. Begin Date: [DATE] and End Date: [DATE]. For future staff, any agency staff, or staff out on leave, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. 3. Systemic Actions taken by Facility include: New admissions and readmitted to the facility have the potential to be affected by the alleged deficient practice. Facility DON and Administrator have conducted a review of all Residents with a diagnosis of Diabetes Mellitus to determine the following: Whether or not the resident is receiving an oral or injectable medication for Diabetes, Monitoring of CBG's have been ordered, Monitoring for signs and symptoms are in place for Hypoglycemia and Hyperglycemia have been ordered, Documentation of providing HS snacks is noted, and Whether or not resident is receiving an accucheck; if they do not have an accucheck ordered, MD notified for recommendations. Completion [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] Education for active nursing staff occurred on Diabetic Management by facility Director of Nurses. Completion: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] Education for active nursing staff occurred on facility policy regarding medication reconciliation by Director of Nurses Order entry is to be verified by 2 nurses. Any unclear orders or orders without parameters must be clarified with resident NP and/or MD. Completion: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] education for active nursing staff was completed regarding MD/NP notification of all admissions and readmissions by Director of Nurses. Completed: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. Active Facility staff will be in-serviced on the Medication Regimen Review process for all admissions and readmissions. Medication orders and resident face must be shared with the consultant pharmacist within 24 hours of admission or readmission. Begin Date: [DATE] and End Date: [DATE] Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. For future staff, any agency staff, or staff out on leave, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. 4. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan of correction for all admissions and readmissions 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. Begin date: [DATE], End date: [DATE]. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as ,d+[DATE] mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admitted [DATE] and diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #4's 5-day MDS with an ARD of [DATE] revealed, in part, she had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #4's current Care Plan revealed the following, in part: Problem: I have Diabetes Mellitus Interventions: Accuchecks per MD orders. Administer my diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #4's Physician Orders dated [DATE] revealed orders on [DATE] for Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100unit/ml inject 42 units SQ daily in a.m. and 32 units SQ daily in p.m. related to Type II Diabetes Mellitus. The medication was started on [DATE]. Further review revealed no order for blood glucose monitoring. Review of Resident #4's Nurses' Notes dated [DATE] revealed, in part, no evidence the physician was notified to obtain an order for blood glucose monitoring. Review of Resident #4's MAR dated [DATE] revealed Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100 unit/mL inject 42 units SQ in a.m. was started on [DATE]. The medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN Further review of the [DATE] MAR revealed Insulin Aspart Prot & Aspart ,d+[DATE] SQ 100 unit/mL inject 32 units SQ in p.m. was started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at p.m. medication pass by S14LPN [DATE] at p.m. medication pass by S6RN There was no documentation of blood glucose monitoring on the [DATE] MAR. Review of Resident #4's Vital Sign History from [DATE] through [DATE] revealed no documentation of blood glucose monitoring. Review of the Emergency Transfer Log from [DATE] through [DATE] revealed the following for Resident #4: Transfer date: [DATE] Location of transfer: local hospital Reason for transfer: low blood sugar Review of Resident #4's emergency room History and Physical Dated [DATE] revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge Summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . An interview was conducted with S5MRLPN on [DATE] at 11:25 a.m. She stated Resident #4 admitted to the facility on [DATE] from a local hospital. She stated she was responsible for reconciling Physician Orders on admission and readmission. She stated Resident #4's hospital discharge orders were for twice daily Insulin Aspart ,d+[DATE] 42 units in the a.m. and 32 units in the p.m. She confirmed she implemented the orders in Resident #4's electronic medical record. She stated the discharge orders did not list an order to obtain blood glucose monitoring. She stated Resident #4's physician should have been contacted to obtain orders for blood glucose monitoring. She confirmed Resident #4's physician was not notified of the insulin order without blood glucose monitoring ordered. An interview was conducted with S6RN on [DATE] at 1:01 p.m. She stated Resident #4 resided on the skilled hall, where she worked, at one time. She confirmed Resident #4 was on ,d+[DATE] insulin twice daily while on her unit and she sent her to the hospital one time for a low blood glucose level. She stated Resident #4 was unresponsive. She stated she administered Glucagon and Resident #4's blood glucose level continued to decline. She confirmed there were no documented blood glucose values for Resident #4 between [DATE] and [DATE] when she went to the hospital and there should have been. An interview was conducted with S1DON and S2ADON on [DATE] at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from [DATE] through [DATE]. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on [DATE] at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from [DATE] through [DATE]. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. An interview was conducted with S1DON on [DATE] at 11:05 a.m. She stated there was no system in place prior to survey entrance to check behind medical records and review hospital paperwork. Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed Resident #2 had diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Heart Failure, Unspecified Atrial Fibrillation, and Alzheimer's Disease. Review of Resident #2's Quarterly MDS with an ARD of [DATE] revealed, in part, she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #2's Care Plan revealed the following, in part: Problem: I have Diabetes Mellitus Goal: I will be free from any signs and symptoms of Hypoglycemia through the review date. Interventions: Accuchecks per MD orders. Administer my diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #2's Hospital Discharge Physician Orders dated [DATE] revealed the following, in part: Change how you take the following medications: Glimepiride (Amaryl) Prescribed Medication List: Glimepiride 2 mg tablet. Start taking on [DATE]. Take one tablet by mouth in the morning and one tablet before bedtime. Hold until PO intake improves. Review of Resident #2's Physician Orders dated [DATE] revealed the resident was prescribed accuchecks BID starting [DATE] through the discontinue date of [DATE]. Resident #2 was restarted on Glimepiride 2 mg PO BID on [DATE]. Further review revealed Accuchecks were not reordered and there were no instructions to hold Glimepiride until PO intake improved. Review of Resident #2's Meal Percentage Intake Documentation from [DATE] through [DATE] revealed the following: [DATE] at Breakfast - ,d+[DATE]% Lunch - not documented Supper - not documented [DATE] at Breakfast - ,d+[DATE]% Lunch - ,d+[DATE]% Supper - ,d+[DATE]% [DATE] at Breakfast - ,d+[DATE]% Lunch - not documented Supper - ,d+[DATE]% [DATE] at Breakfast - ,d+[DATE]% Lunch - ,d+[DATE]% Supper - ,d+[DATE]% [DATE] at Breakfast - ,d+[DATE]% Lunch - ,d+[DATE]% Supper - ,d+[DATE]% Review of Resident #2's MAR dated [DATE] revealed Glimepiride Tablet 2 mg BID was ordered on [DATE] and started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S7LPN [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S8LPN [DATE] at a.m. medication pass by S9LPN [DATE] at p.m. medication pass by S8LPN There was no documentation of blood glucose monitoring on the above dates. Review of Resident #2's Vital Sign Record dated [DATE] through [DATE] revealed the following Blood Glucose entry: [DATE] at 7:00 a.m. - 30 mg/dL by S9LPN Further review revealed no other entry between [DATE] through [DATE]. Review of Resident #2's Nurses' Notes for [DATE] revealed the following, in part: [DATE] at 8:01 p.m. by S10LPN: Resident readmitted to the facility from a local hospital. [DATE] at 9:38 a.m. by S9LPN: Upon performing daily blood glucose, resident was noted with a reading of 31. Unresponsive, shallow respirations of 14, periods of apnea for approximately ,d+[DATE] seconds then resident has a deep gurgling breath. Glucagon 1 mg administered at 7:00 a.m., recheck at 7:06 a.m. (34), recheck at 7:14 a.m. (40). Resident remains unresponsive and continues with short periods of apnea. Another gram of Glucagon administered. Resident remains unresponsive, glucose gel administered blood glucose 50. Resident remains unresponsive, EMS arrives checks blood glucose 54 . Transported at 7:30 a.m. via stretcher. Further review of the Nurse's Notes revealed no evidence Resident #2's physician was contacted for a clarification of the Glimepiride order or to obtain blood glucose monitoring. Review of Resident #2's Emergency Department Physician Notes dated [DATE] at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's ICU Physician Progress Note dated [DATE] revealed the following, in part: Assessment and Plan: Hypoglycemic Coma: Possibly due to Glimepiride and/or poor oral intake. Seizures: Likely due to Hypoglycemia. Being treated with Levetiracetam, Valproic Acid, Propofol, and Lacosamide. MRI indicates poor prognosis. Respiratory failure: Due to above. Review of Resident #2's Neurology Physician Progress Note dated [DATE] revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S11CNA on [DATE] at 10:36 a.m. She confirmed she took care of Resident #2 regularly and her appetite was poor since returning from the hospital on [DATE]. She stated she was assigned to Resident #2 on [DATE], and she ate less than 25% of breakfast and 75% of lunch. An interview was conducted with S12CNAS on [DATE] at 11:15 a.m. She stated when Resident #2 returned from the hospital on [DATE], her appetite had decreased. She stated Resident #2 ate less than 25% of most meals. She stated she was not consuming enough calories. An interview was conducted with S13CNA on [DATE] at 2:40 p.m. She confirmed she was assigned to Resident #2 on [DATE] from 2:00 p.m. to 6:00 a.m. She stated throughout her shift on [DATE], Resident #2 was sleepy. She stated she slept throughout her rounds and would only moan when she would turn her to change her brief. She stated Resident #2 refused supper on [DATE] and she reported this to the nurse. She stated Resident #2 did not wake up to consume snacks on her shifts on [DATE]. She reviewed Resident #2's documented meal intake and verified the documentation was inaccurate. She confirmed Resident #2 consumed 0% of her supper meal on [DATE]. She stated Resident #2 had consumed significantly less at meals and refused more meals since she returned from the hospital on [DATE]. An interview was conducted with S8LPN on [DATE] at 2:16 p.m. She stated she had been working at the facility for three weeks. She stated she worked the 2:00 p.m. to 10:00 p.m. shift on Resident #2's hallway. She stated Resident #2 never received blood glucose monitoring on her shift. She confirmed she administered Glimepiride to Resident #2 on the evening of [DATE]. She stated she was unaware Resident #2 did not eat her supper on [DATE]. She stated she was unaware Resident #2's Glimepiride should have been held until her intake improved. An interview was conducted with S9LPN on [DATE] at 9:42 a.m. She confirmed she was the nurse that sent Resident #2 to the hospital on the morning of [DATE]. She stated Resident #2's blood glucose level was 30 mg/dL and Resident #2 did not respond to any stimuli. She reviewed Resident #2's Medical Record and confirmed Resident #2 did not have an order for blood glucose monitoring after her return from the hospital on [DATE] and did not have blood glucose levels documented until [DATE] at 7:00 a.m. when it was 30 mg/dL. She confirmed on [DATE], Resident #2 began receiving Glimepiride 2 mg twice daily. She stated Resident #2's appetite was very poor. She stated Resident #2 ate on average ,d+[DATE]% of meals. She stated Resident #2 frequently skipped meals. She stated Resident #2's appetite had decreased since her return from the hospital on [DATE]. She stated she was not aware Resident #2's Glimepiride should have been held until her appetite improved. She stated if she had known, she would have held Resident #2's Glimepiride and notified the physician. An interview was conducted with S5MRLPN on [DATE] at 11:40 a.m. She stated she reconciled Resident #2's physician orders per the discharge orders received from a local hospital on [DATE]. She stated the discharge orders did not list to obtain blood glucose monitoring, so she discontinued them. She stated she should have contacted Resident #2's physician to see if she wanted to continue blood glucose monitoring for Resident #2. She stated she entered the order for Glimepiride 2 mg twice daily on [DATE] to begin on [DATE]. She confirmed she did not add to hold the medication until Resident #2's appetite improved. She stated she should have reviewed Resident #2's meal intake and contacted Resident #2's physician to obtain a clarification to the Glimepiride order. She stated there was not a system in place for anyone to check physician orders behind her. An interview was conducted with S1DON on [DATE] at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on [DATE] if appetite improved. She stated that was subjective and she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from [DATE] until [DATE] at 7:00 a.m. when there was a reading of 30 mg/dL. She stated there was not a system in place to check physician orders behind S5MRLPN. An interview was conducted with S3MD on [DATE] at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on [DATE]. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. A telephone interview was conducted with S4NP on [DATE] at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on [DATE]. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with Medical Records at a local hospital on [DATE] at 4:58 p.m. She stated Resident #2 expired on [DATE].

Based on interview and record review, the facility failed to ensure the Quality Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies following identified errors in clarification and obtaining parameters of antidiabetic medication on admission orders for 1 (#RF2) of 6 (#F4, #RF1, #RF2, #RF3, #RF4, #RF5) residents selected for receiving antidiabetic medications. This deficient practice resulted in an immediate jeopardy situation for Resident #RF2 on 07/14/2023 when blood glucose parameters were not clarified or obtained from the physician for the order of insulin lispro subcutaneous 100 units/ml inject 7 units before meals. On 07/24/2023, Resident #RF2's blood glucose dropped from 102 to 58 after insulin lispro was administered. Resident #RF2 received 40 doses of subcutaneous insulin lispro without clarifying blood glucose parameters with a physician from 07/14/2023 to 07/28/2023. On 07/29/2023, the physician ordered to hold the insulin if the blood sugar was less than 150. Resident #RF2 was administered 9 doses of subcutaneous insulin lispro outside of physician's blood glucose parameters from 07/29/2023 to 08/03/2023 which had the likelihood of causing severe injury, harm or death if not immediately corrected. SF15ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 4:31 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 9:00 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to ensure the Quality Assurance (QA) committee identified a quality deficiency and failed to monitor and evaluate the effectiveness of processes implemented in response to an appropriate plan of action to correct the deficient practices cited on the last complaint survey. The facility failed to have a system in place to ensure: Residents that received anti-diabetic medications had clarification of orders if blood glucose parameters were not present, Physician's orders were followed. 1. The orders for antidiabetic medications for Resident #RF2 were clarified by SF6RN on 08/03/2023 by SF3MD. 2. Any of the 22 residents receiving antidiabetic medications with parameters have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: On 08/03/2023 Administrator and DON were educated by the Regional QI Nurse regarding the job duties and responsibilities associated with: 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications was put in place 08/03/2023. The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion date for training is 08/09/2023. If QA committee determines compliance is achieved, then the end date 09/15/2023. If Compliance is not achieved then 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications continue for another 6 weeks or longer, as determined by the QA Committee. Facility DON, Administrator, QI Nurse or the Clinical Care Coordinators have conducted a review of all Residents receiving antidiabetic medication to determine the following: Whether or not the antidiabetic medication was given following the MD orders with the parameters ordered. Completed 08/03/2023. The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. On 08/03/2023 education began Nurses on Diabetic Management which included the following: The Regional QI Nurse, educated SF1DON and SF2ADON, o who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. o Following Physician orders that include parameters: The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. 1. 08/03/2023 Education for active nursing staff occurred on hovering over the see more option on the MAR to see additional details. This was done by the Director of Nurses: Completion date of 08/09/2023. 2. 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications was put in place 08/03/2023 at 7:01pm. Completion date of 08/09/2023. 3. DON and/or ADON will review execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications. completion 08/09/2023 o For future staff, any agency staff, or staff out on leave, or non-scheduled staff, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. Completion 08/09/2023. QAPI Committee members including but not limited to Administrator, DON and ADON, will review surveillance tools (2 Nurse Verification tool used to monitor accuracy of the amount of blood glucose value/given or held and verification of parameters, and the Execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications), 2 times per week for 6 weeks for compliance Start Date will be 08/08/2023 and end date will be 09/15/2023. If non-compliance is identified, then will restart education for staff and monitoring by QAPI Committee members will continue for another 6 weeks. 4. Administrator will review the implementation of the following: A. That a review of the residents with orders for antidiabetic medications with parameters are monitored by the DON/ADON to ensure ordered medications are delivered correctly beginning on 08/04/2023 and continuing 5 times per week for 2 weeks, and if continued compliance then 3 times per week for 4 weeks, and if continued compliance then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. If non-compliance identified, then will restart education and monitoring 5 times per week. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. B. The completion of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, and if continued compliance then 3 times per week for 4 weeks, and if continued compliance then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. If non-compliance identified, then will restart education and monitoring 5 times per week. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. C. QAPI Committee members including but not limited to Administrator, DON and ADON, will review surveillance tools (2 Nurse Verification tool used to monitor accuracy of the amount of blood glucose value/given or held and verification of parameters and the Execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications), and conduct at least 2 observations of anti-diabetic medication administration (4 per week), 2 times per week for 6 weeks for compliance Start Date will be 08/08/2023 and end date will be 09/15/2023. If non-compliance is identified, then will restart education for staff and monitoring by QAPI Committee members will continue for another 6 weeks. The deficient practice continued for more than minimal harm for the remaining residents identified by the facility as receiving antidiabetic medications Findings: Cross Reference F-726 Cross Reference F-867 Cross Reference F-684 Review of the Facility Policy titled Quality Assurance and Performance Improvement (QAPI) Program revealed the following, in part: Program: Each facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life for our residents. Design and Scope At a minimum, the program must: Address all systems of care and management practices (which may include resident finances and personal funds, admission and discharge practices). Include clinical care, quality of life and resident choice. Utilize the best available evidence and performance indicators to measure of quality and facility goals. Implementation: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Data collection for QAPI meetings should include, but is not limited to, infection control surveillance and tracking, infectious disease outbreaks, healthcare associated infections, antibiotic stewardship program related to antibiotic use and resistance data, wound logs, drug regimen reviews. Adverse events, use of antipsychotic medications, medical errors, incident and accident reports, cases of physical or sexual abuse, survey results, quality assurance and performance improvement projects. Adverse Events (3 categories- medication, care, and infection related) Thorough analysis as to why occurred. Implementation of corrective actions (define the problem, develop measurable goals, step by step interventions to correct the problem) Monitoring to ensure desired outcomes are achieved and sustained. Performance Improvement Projects: Interventions are designed to address the underlying causes, and once implemented, the team closely monitors results to determine if changes are yielding the expected improvement or if the interventions should be revised. Data Analysis, Monitoring and Feedback The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. Data and information collected are reviewed by the committee and prioritized according to the risk, volume, and potential problems. It is not necessary to collect all data at the same frequency. The facility may develop a frequency reviewing high risk or problem prone areas more frequently until performance reached a satisfactory level, then collect data less frequently. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals Review of Resident #RF2's Nursing Facility Orders Dated 07/14/2023 at 3:24 p.m., revealed insulin lispro100 unit/ml 7 units subcutaneous 30 minutes before meals. No parameters for administration were noted or clarified. Further review of the two nurse verification of Resident #RF2's hospital discharge orders and nursing facility orders revealed signatures by SF2ADON and SF5MRLPN on 07/14/2023. Review of Resident #RF2's Fax Form for Non-Emergency Communication dated 07/28/2023 at 11:06 a.m. revealed, 07/28/2023, hold Insulin at meal times of blood sugar less than 150. Per SF4NP. Review of Resident #RF2's MARs from 07/14/2023 to 08/03/2023 revealed the following, in part: Start Date: 07/14/2023 Discontinue Date: 07/28/2023 Insulin lispro subcutaneous100unit/ml Inject 7 unit subcutaneously before meals. Start Date: 07/29/2023 Insulin lispro subcutaneous 100 units/ml Inject 7 unit subcutaneously before meals. Hold if blood sugar is less than 150. Review of the Resident #RF2's MAR from 07/14/2023 to 08/03/2023 revealed that Resident #RF2 received 40 doses of subcutaneous insulin lispro without blood glucose parameters from 07/14/2023 to 07/28/2023. Resident #RF2's MAR also revealed insulin lispro was administered 9 doses outside of physician's blood glucose parameters from 07/29/2023 to 08/03/2023. On 08/04/2023 at 12:55 p.m., an interview was conducted with SF1DON. SF1DON explained the facility had implemented a 2 check system for when orders were entered into the system for resident admissions and readmissions. SF1DON stated SF5MRLPN put the hospital orders for Resident #RF2 into the system but did not activate them. SF1DON stated SF2ADON reviewed the orders on 07/14/2023 for accuracy, activated them and they both signed off on the review. SF1DON stated SF5MRLPN no longer works at the facility. On 08/04/2023 at 1:00 p.m., an interview was conducted with SF2ADON. SF2ADON confirmed on 07/14/2023 she reviewed and activated an order for insulin lispro 7 units subcutaneously before meals. SF2ADON further confirmed she did not contact the physician for order clarification before the orders were activated. SF2ADON stated Resident #RF2 received insulin lispro 7 units subcutaneously from 07/14/2023 to 07/28/2023 without blood glucose parameters. SF2ADON stated on 07/28/2023 she notified the physician and orders were obtained for blood glucose parameters. SF2ADON stated she was not aware the facility implemented a procedure to clarify antidiabetic medications if blood glucose parameters were not specified in the physicians order. On 08/04/2023 at 1:05 p.m., an interview was conducted with SF1DON. SF1DON confirmed Resident #RF2 received insulin lispro 7 units subcutaneous from 07/14/2023 to 07/29/2023 without blood glucose parameters, and staff should have clarified the orders with the physician before the order was activated. On 08/04/2023 at 3:13 p.m., an interview was conducted with SF15ADM and SF1DON. The aforementioned findings were reviewed and confirmed with SF15ADM and SF1DON. SF15ADM stated Resident #RF2's subcutaneous insulin lispro orders should have been clarified regarding blood glucose administration parameters. SF15ADM stated staff should get clarification for insulin orders without blood glucose parameters on admission /re-admission. SF15ADM confirmed Resident #RF2 was admitted to the facility on [DATE] and the order was clarified on 07/28/2023, two weeks after his admission. SF15ADM stated MARs were checked daily for accuchecks and insulin administration. SF15ADM stated he did not know how SF2ADON missed this. SF15ADM confirmed their interventions for clarifying orders were not effective. SF15ADM confirmed the deficiencies with Resident #RF2 had not been identified and corrected in their QAPI. SF15ADM confirmed the facility was not in compliance on 07/13/2023 and there was no new QAPI opened or new measures implemented after 07/14/2023.

Based on interviews, observations, and record review, the facility failed to ensure staff were educated on which residents were at risk for falls and implemented interventions to prevent or reduce the risk of accidents for 1(#2) of 5(#1, #2, #3, #4, #5) residents reviewed for falls. Findings: Review of the facility's policy, Falls and Fall Risk, Managing, revealed the following, in part: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specified risks and causes to try to prevent the resident rom falling and to try to minimize complications from falling. Fall Risk Factors 2. Resident conditions that may contribute to the risk of falls include: b. infection e. lower extremity weakness i. functional impairments 3. Medical factors that contribute to the risk of falls: b. heart failure d. neurological disorders e. balance and gait disorders Resident-Centered Approaches to Managing Falls and Fall Risk 6. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 2. If interventions have been successful in preventing falling, staff will continue the interventions . Review of the Clinical Record for Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses, which included, Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Peripheral Vascular Disease, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Dysarthria Following Cerebral Infarction. Review of the Quarterly MDS with an ARD of 11/30/2022 revealed Resident #2 had a BIMS of 12, which indicated he was moderately cognitively impaired. Further review revealed Resident #2 required limited assistance of one staff member for transfers and toileting, and was coded as not steady, only able to stabilize with staff moving on and off the toilet. MDS also revealed Resident #2 uses a wheelchair for mobility. Review of the current Care Plan for Resident #2 revealed the following, in part: Problem: I am at risk for injury related to falls. Approaches: 12/27/2022 CNA educated to make Resident's bed during morning ADL care 12/24/2022 Staff and Resident compromised on Resident's time to be changed and put to bed at 9:15 p.m. 12/18/2022 Resident counseled to call for assist with transfers in the bathroom; call for assist signs placed in bathroom. Resident educated on how to turn light on in restroom and if the light on the wall goes off use call light in restroom, do not attempt to get up and turn wall light on. 12/11/2022 Resident educated and encouraged to allow staff to assist with toileting and putting clothes on for bed. 10/31/2022 Resident reeducated on using call light when needing to toilet, resident non-compliant, staff instructed to make rounds on resident every 2 hours and ask to toilet. 10/25/2022 Resident referred to therapy for evaluation. 10/13/2022 Drug test scheduled. 12/14/2018 Bedside commode rails placed over toilet to assist resident with balance with standing up from toilet. On 01/11/2023 at 3:37 p.m. and on 01/12/2023 at 9:45 a.m., observations were made of Resident #2's bathroom on Hall A. There was no bedside commode rails in place over his toilet noted. On 01/12/2023 at 10:00 a.m., an interview was conducted with S3CNA. She said Resident #2 was recently moved to Hall A due to his diagnosis of Covid-19. She stated she was not aware if Resident #2 was on fall precautions. On 01/12/2023 at 10:30 a.m., an interview was conducted with S4PTA. She said Resident #2 has had multiple falls. She said when he was first moved to Hall A, he was too weak to get out of the bed, but has regained strength this week and has the ability to try to transfer on his own, even though he was not supposed to. On 01/12/2023 at 10:48 a.m., an interview was conducted with S2MDSN. She said that Resident #2 was care planned to have bedside commode rails placed over the toilet to assist the resident with balance. She stated the resident should have bedside commode rails over the toilet in his new room on Hall A. On 01/12/2023 at 11:00 a.m., an interview was conducted with S1DON. She confirmed Resident #2 was care planned for a bedside commode rails over the toilet. She confirmed Resident #2 did not have a bedside commode rails over the toilet in his room on Hall A. She also confirmed all direct care staff were responsible for following residents' care plans, and should be aware if a resident was a fall risk.

Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from physical abuse by staff for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents when S8CNA threw a can of peanuts at Resident #1. Findings: Review of the facility's Abuse - Neglect of a Resident, Reporting Abuse Elder Justice Act and Affordable Care Act policy revealed, in part: Abuse defined is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's MDS with an ARD of 10/10/2022 revealed the resident had a BIMS of 8, which indicated moderate cognitive impairment. Review of Resident #1's Nursing Notes revealed: On 10/12/2022 at 1:32 a.m., Resident #1's light was on. Resident stated see that can over there she threw it at me and hit me in the eye. Calmed resident. S8CNA sent home. Resident was able to point out S8CNA in a line up and DON notified of abuse reported by resident at 11:45 p.m. signed by S5LPN. On 10/24/2022 at 2:35 p.m., an interview was conducted with S9CNA. S9CNA confirmed she worked the 10:00 p.m. to 6:00 a.m. shift on 10/11/2022 and was assigned to care for Resident #1. S9CNA confirmed S8CNA was also caring for Resident #1. S9CNA stated Resident #1 turned the call light on and S8CNA went into the resident's room to answer it. S9CNA stated S8CNA exited the room and said Resident #1 told her to get the f*** out of his room. S9CNA stated Resident #1 put the call light on again. S9CNA saw S8CNA enter Resident #1's room again. S9CNA stated about 30 minutes after S8CNA answered the call light for Resident #1, S5LPN asked her and S8CNA to go to Resident #1's room. S9CNA stated Resident #1 was alert when she and S8CNA entered the room. S9CNA stated S5LPN asked Resident #1 to identify which CNA had thrown the peanut can at him. S9CNA stated Resident #1 immediately pointed to S8CNA. S9CNA stated Resident #1's eye had a cut above it and was swollen. S9CNA stated she saw a peanut can across the room by the resident's closet. S9CNA stated S8CNA was told to leave. On 10/25/2022 at 8:50 a.m., an interview was conducted with Resident #1's daughter. She said Resident #1 told her that S8CNA had hit him in the head with a peanut can. She said the family immediately removed him from the facility after being notified of the incident. She said Resident #1 had pain after S8CNA threw the peanut can at him. She said he did not want to go to hospital or any other nursing home and was fearful following this incident. On 10/25/2022 at 9:00 a.m., an interview was conducted with S5LPN. S5LPN confirmed she worked the 10:00 p.m. to 6:00 a.m. shift on 10/11/2022 and was assigned to care for Resident #1. S5LPN stated during her initial rounds at 10:30 p.m., Resident #1 was noted to be calm with no cut or injuries to the resident's face. S5LPN stated around 11:45 p.m. she saw Resident #1's call light on and went to answer it. S5LPN stated Resident #1 was upset and told her that the young lady who just left out of here was mad because I put my light on. S5LPN stated Resident #1 told the CNA well that's your job isn't it? S5LPN stated Resident #1 told her after he made the remark the CNA threw the peanut can at him. S5LPN stated she noticed a small bleeding cut about the size of a pinky fingernail above Resident #1's left eye. S5LPN stated Resident #1 did not know the name of the CNA. S5LPN stated she asked another nurse, S4LPN, and the 2 CNAs on the hall to go to Resident #1's room. S5LPN stated Resident #1 was asked to identify the CNA who threw the peanut can at him. S5LPN stated Resident #1 identified S8CNA. S5LPN stated she recalled seeing a peanut can on the floor against the wall. S5LPN stated Resident #1 stated he had pain after the incident and asked for a pain reliever. S5LPN stated S8CNA did not deny Resident #1's accusation. On 10/25/2022 and 10/26/2022 surveyor attempted to contact S8CNA four times and was unsuccessful. On 10/25/2022 at 10:00 a.m., an interview was conducted with S3DON. She confirmed she had received a phone call from S5LPN on 10/12/2022 at midnight to inform her of Resident #1's alleged abuse from S8CNA. S3DON stated S8CNA hit Resident #1 with a peanut can. She said S8CNA was terminated that night and never returned to facility. S3DON stated the facility implemented training on abuse but has not implemented monitoring to prevent reoccurrence. On 10/25/2022 at 11:05 a.m., an interview was conducted with S1ADM. He said he received a call from S3DON on the night of 10/12/2022 regarding the incident involving Resident #1 and S8CNA. He said when he arrived to the facility the police were onsite and family had Resident #1 in the car. He said Resident #1 had a fingernail size cut and puffiness to the left side of his eye. S1ADM said he spoke with S8CNA and she reported she did not know what happened, then changed her story to say that Resident #1 threw the can at her. He confirmed S8CNA was terminated that night. S1ADM confirmed Resident #1 did suffer an injury after the interaction with S8CNA. S1ADM stated the facility implemented training on abuse but has not implemented monitoring to prevent reoccurrence. On 10/25/2022 at 12:54 p.m., an interview was conducted with S10CC. She said she worked 10/11/2022 from 2:00 p.m. to 10:00 p.m. and had cared for Resident #1. She confirmed when her shift ended at 10:00 p.m., Resident #1 did not have any facial cuts or swelling.

Based on interviews and record reviews, the facility failed to report an injury of unknown origin to the state survey agency in the appropriate time frame for 1 (#2) of 6 (#1, #2, #3, #4, #5, and #6) residents sampled. Findings: A review of the Facility's policy titled Abuse- Neglect of a Resident, Reporting Abuse Elder Justice Act and Affordable Care Act revealed in part: 2.0 Definitions Injuries of unknown origin- An injury should be classified as an injury of unknown source when: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury, location of the injury or the number of injuries observed at one particular point in time or incidence of injuries over time. Investigation: 2. For incidents meeting State Agency criteria a report must be initiated within 24 hours of noted event or immediately (no more than 2 hours) if a reasonable suspicion of a crime exists that involves serious bodily injury or a criminal sexual assault. A State Agency report is required if: major injuries of unknown origin are noted which could possibly be the result of abuse or neglect (fractures, [CONDITION(S)], suspicious contusions, head injuries etc.) A review of Resident 2's medical record revealed, in part: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's quarterly MDS with an ARD 01/05/2022 revealed a BIMS of 8, which indicated she was moderately cognitively impaired and required one person assistance with ADL's. A review of the Incident/Accident Log for Resident #2 dated March 2022 revealed, in part: 03/15/2022 Injury of unknown origin. A review of the facilities investigation report revealed, in part: Called to Resident #2's room on 03/15/2022 at 4:30 p.m. by the CNA and treatment nurse. Treatment nurse removed pants and observed bruising to right leg from knee down including right foot. Resident denied pain and unable to state what happened to her leg. Received orders to send resident to local emergency room for evaluation. Administrator notified and State Agency report initiated on 03/15/2022. Review of tapes revealed resident #2 was in her wheelchair all day for activities. Tapes did not reveal a bump or fall to right leg. Resident #2's normal behavior was in the dining room for meals and then she went back to bed. A review of medical records from a local emergency room revealed, in part: X-Ray right knee 4+ view right, result date: 03/15/2022 Impression: 1. Suspected tibial plateau fracture 2. Moderate-sized suprapatellar joint effusion 3. Incompletely imaged orthopedic hardware in the right femur diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the orthopedic consult from the local emergency roiagnom on [DATE] at 8:42 p.m. revealed in part: Primary dx: Possible right tibial plateau fracture A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Assessment/Plan: Ecchymosis Hospital records reviewed. Radiologist seems very clear that there was no fracture seen. Discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Impression: a [AGE] year old female with a possible occult fracture of the right tibial plateau. Plan: This is an unknown injury. Her x-rays reveal that maybe she has a small fracture line but it is not displaced. A review of the facility incident report revealed the facility opened a report with the state survey agency on 03/15/2022, but then on 03/22/2022 rescinded the report. An interview was conducted on 10/25/2022 at 11:22 a.m. with S3DON. She said Resident #2 was in her wheelchair on 03/15/2022. She said the wound care nurse called her to Resident #2's room when she noticed bruising and swelling to the right lower leg. She further stated the bruising was unknown and Resident #2 was sent to a local emergency room for evaluation. She stated a report was initiated on 03/15/2022 with the state agency. She explained her investigation revealed Resident #2 did not have a fracture so the facility rescinded the report to the State Agency. An interview was conducted on 10/26/2022 at 11:00 a.m. with S1ADM. He confirmed a State Agency report was opened when the facility found bruising to Resident #2's right leg. He said on 03/21/2022, Resident #2 had an appointment with a local orthopedic surgeon and was accompanied with staff. He further stated the staff verbally reported to him there was not a fracture noted to Resident #2's right leg. He confirmed he then rescinded Resident #2's State Agency report for injury of unknown origin that was submitted on 03/15/2022. S1ADM reviewed the hand written orthopedic note dated 03/21/2022 and confirmed it was not legible. Surveyor provided S1ADM dictated note dated 03/21/2022 and confirmed it said possible fracture. S1ADM stated if he had known it was a possible fracture he would not have requested the State Agency report be rescinded.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a mechanical lift transfer for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1 on [DATE] at 11:13 a.m., when S4CNA transferred the resident from chair to bed without assistance of another person and utilized the mechanical lift. Resident #1 fell from the lift sling during the transfer and landed on the floor resulting in back pain and cut to upper lip. Resident #1 was transferred to the hospital on [DATE] and diagnosed with [CONDITION(S)]. S4CNA neglected to follow the resident's care plan of using two-person staff assistance to transfer the resident via mechanical lift. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's Mechanical Lift Policy revealed the following, in part: Each resident will have a lift assessment completed by a licensed nurse upon admission, annually, quarterly, and with significant change. All staff are responsible for using the required number of assistants for resident transfer and lifts, as well as the appropriate colored sling designated in the residents' personal lift assessment. Two persons are always required for stand up lift and bed lifts. Failure to utilize a mechanical lift when the use of this equipment is indicated per the residents lift assessment could result in disciplinary action up to and including termination of employment. Staff will be trained in the use of mechanical lifting equipment/devices annually and as needed. A return demo will be completed during orientation and as needed. A staff competency checklist must be completed upon hire and at least annually. All trained staff members will read and sign the Lifting Policy Acknowledgement. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, [CONDITION(S)], Metabolic [CONDITION(S)], Right Knee [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Chronic Kidney disease, and Anxiety disorder. Review of Resident #1's MDS, with an ARD of [DATE], revealed the following, in part: BIMS (Brief Interview for Mental Status) of 14 which indicated the resident was cognitively intact. Bed mobility- extensive assistance/2-person assist; Transfer- extensive assistance/2-person assist. Review of Resident #1's current Care Plan revealed the following, in part: [DATE] Problem: Self-care deficits related to weakness, secondary to [CONDITION(S)] to right knee, Congestive Heart Failure, and [CONDITION(S)]. Approaches: Resident #1 required mechanical lift with two staff person assistance for transfers and use of extra-large standard sling. Review of Resident #1's Nursing Notes revealed the following, in part: [DATE] 1:29 p.m., CNA informed the nurse that resident was on the floor. Upon arrival resident sitting up with back resting against the side of the bed with mechanical lift still in place. Resident and CNA states In attempts to transfer resident from chair to bed the mechanical lift tilted. Resident with complaint of back pain and bleeding from a cut on her lip. Vital signs obtained. EMS contacted and transferred her to the local hospital. Review of the hospital records dated [DATE] at 3:07 p.m. revealed Resident #1 expired with final diagnosis of [CONDITION(S)], Respiratory Arrest, and Fall Initial Encounter. Review of the facility's Investigative Report revealed the following, in part: [DATE] at approximately 11:13 a.m., the floor nurse came to S1DON to report there had been a fall in Resident #1's room and the resident was bleeding. S1DON noted Resident #1 sitting on the floor with back against the bed. Blood noted to mouth and face. Resident on lift pad and lift was on its side next to resident. S4CNA was standing in front of Resident #1. Resident#1 leaves with ambulance at 11:45 a.m. for hospital ER transport and evaluation. Mechanical lift was removed from service. Responsible party and physician notified. Based on witness statements, review of training records and assessment of equipment investigation revealed S4CNA understood the procedures involved for proper lift transfer, had proper equipment available for use, and chose not to follow the proper process which led to an improper transfer. Facility terminated S4CNA and reported her actions to registry board. S4CNA failed to secure a second person for the transfer. A finding of neglect is substantiated as this aide failed to follow the resident's care plan. On [DATE] at 10:15 a.m. a telephone interview was conducted with S4CNA. She said she provided care to Resident #1 on [DATE]. She said she was aware Resident #1 required two-person assistance with transfers using the mechanical lift. She said on [DATE] at 11:55 a.m., she was told by S8MS to hurry and get Resident #1 out of bed. She said she told S5CNA she needed assistance, but she was busy caring for another resident. She said as she started to lift Resident #1 up with the lift, the lift tilted and Resident#1 fell on to the floor. She said Resident #1 busted her lip but was alert and talking coherently. She said S2DON arrived and started to yell saying the mechanical lift's base was closed. She said Resident #1 was transferred to a local hospital. S4CNA confirmed she had received training on the mechanical lift and was aware Resident #1 required 2-person assistance with transfers. She said she felt a lot of pressure to hurry and transfer Resident #1 on [DATE] and confirmed that was the reason she transferred her unassisted. On [DATE] at 12:04 p.m. an interview was conducted with S7CNAS. She said on [DATE] at 1:00 p.m., she was summoned by S2DON to report to her office to discuss an injury suffered by Resident #1 after S4CNA transferred her unassisted via the mechanical lift. She said S4CNA told her she attempted to transfer Resident #1, unassisted, from the chair to the bed using the mechanical lift and Resident #1 fell on to the floor. She said she provided in-services and training to all nurses and CNAs on the use of the mechanical lift before and after this incident. She said she provided demonstrations and in-services to all nurses and CNAs before they provided care to the residents. She said S4CNA was sent home the day of the incident and could not return until investigation was complete. She said S4CNA should not have used the mechanical lift unassisted to transfer Resident #1 from the chair to the bed on [DATE]. On [DATE] at 8:35 a.m. a telephone interview was conducted with S5CNA. She said she worked on [DATE] when Resident #1 fell from the mechanical lift. She verified she had been trained on the use of the mechanical lift. She said Resident #1 was a two-person assist for all transfers. She said she was not present when Resident #1 fell from the lift. She said she was caring for another resident when she heard a loud boom sound coming from Resident #1's room. She said soon after she heard the loud boom, S4CNA asked her for assistance. She said when she arrived in the room, she observed Resident #1 on the floor bleeding from her face. She said the lift was turned over. She said she left room when SLPN and S2DON arrived. On [DATE] at 11:35 p.m. an interview was conducted with S6CNA. She said Resident #1 could sit on the bed on her own but required 2 person assistance with mechanical lift transfers. On [DATE] at 11:40 a.m. an interview was conducted with S8MS. He said on [DATE], he was standing in the doorway to Resident #1's room when he observed S4CNA lifting Resident #1 unassisted using the mechanical lift from the chair to the bed. He said Resident #1 fell to the floor when the lift tipped over. He said Resident #1 landed on the floor and was in a sitting position next to the bed. He said Resident #1 was slouched over to the right side after the fall. He said the metal handle of the lift hit Resident #1 on the mouth. He said Resident #1 was alert and oriented after the fall. He said Resident #1 was transferred to the local hospital by ambulance. On [DATE] at 10:47 a.m., an interview was conducted with S2DON. She confirmed she was aware of Resident #1 falling out of a mechanical lift on [DATE]. She explained on [DATE] she was called to the room and observed Resident #1 sitting on top of the lift pad on the floor with a busted lip and the mechanical lift on its side. She stated the base to the lift was closed. She stated Resident #1 complained of pain and was sent to the local hospital for assessment and treatment. She said S4CNA was trained and competent on using 2-persons with mechanical lift transfers and was aware Resident #1 required a mechanical lift. She explained after investigation, it was determined S4CNA was in a rush and chose not to get a second staff member to assist her with the transfer which resulted in Resident #1 falling. She confirmed there were multiple staff present during the shift that could have assisted with the transfer. She stated immediately after the incident all nursing personnel were retrained on the mechanical lift policy and could not work on the floor until it was completed. She said staff were also trained on the mechanical lift in [DATE] and again yesterday. She stated all new staff, including agency staff, received training on the mechanical lift and were required to perform a return demonstration in orientation. She stated a check off list was now placed in the employee files. She stated the facility implemented new measures requiring a nurse to be one of the staff present during all mechanical lift transfers. She also said each mechanical lift transfer had to be documented in a monitoring log and include what staff were present for the transfer. She stated she reviewed this log once to twice a week and looked at all mechanical lift transfers that had occurred for compliance. She stated the lift was also immediately taken out of service until an inspection could be completed. She said there was no malfunction noted in the lift during the inspection. She stated she performs spot checks at random times to ensure staff are following proper procedures for mechanical lift transfers and this practice currently has no end date. She confirmed there had been no accidents with mechanical lift transfers since [DATE]. S2DON presented an employee roster showing all required staff had received training on mechanical lift transfers and completed competencies. On [DATE] at 12:47 p.m. this surveyor and S1ADM viewed camera footage from [DATE], surrounding the time of the incident with Resident #1. The following was observed and confirmed by S1ADM. S4CNA entered Resident #1's room at 11:05 a.m. and was in the room alone at the time of the incident. S8MS stood in doorway of the Resident #1's room and was observed leaving the doorway and returned shortly with S3LPN entering room at 11:13 a.m. On [DATE] at 12:47 p.m., an interview was conducted with S1ADM. He said he was aware of the mechanical lift fall incident with Resident #1 on [DATE]. He stated he was part of the investigation team, including writing an incident report. He said after the incident the mechanical lift was removed from service and an inspection was performed with no malfunctions noted. He confirmed the investigation revealed S4CNA had received adequate training and was well aware of the policy on mechanical lift transfers. He confirmed S4CNA's choice of action to use lift alone resulted in a fall for Resident #1. He said all staff members who provided direct resident care were immediately retrained on the proper use of a mechanical lift and the policies and procedures required for 2-person assistance. These staff were not allowed to work until the training was completed. He said after the incident on [DATE], the facility implemented and continued a monitoring process for staff education and performance related to transferring residents with a mechanical lift. He said the process included weekly review of all binder documentation to monitor any residents transferred with a mechanical lift for compliance. He said S2DON was responsible for the monitoring. S2DON reported results to him ,d+[DATE] X weekly. He said spot checks of staff compliance would continue and the situation would be monitored through the Quality Assurance program indefinitely. He said the Quality Assurance coordinator will do quarterly trainings for at least a year and then the Quality Assurance team will reevaluate to see if training is needed after that. Multiple Nurses and CNA's were interviewed about the use of the mechanical lift. All staff interviewed were knowledgeable about the facility's policy that two trained staff members should be present, with the supervision of a nurse, when lifting a resident using the mechanical lift. All staff members stated they had received multiple trainings on the proper use of mechanical lifts. Three random residents, who required use of a mechanical lift for transfers, were observed having two or more staff members and the supervision of a nurse present when the mechanical lift was used on them. Observations were made, on [DATE] and [DATE], by surveyors, of nursing staff operating the mechanical lift. No issues were noted. The facility has implemented the following actions to correct the deficient practice: [DATE]- Continuous Quality Assessment and Improvement Corrective Action Plan: [DATE]- Binder placed on each hall with monitoring tool for documentation of all lifts. I. Immediate in-service of all nursing staff on skills for lift II. Lift taken out of service and inspected III. All lifts have to have nurse present IV. No employee to work prior to retraining on lift skills V. Weekly review of nurse oversight of lift transfers by Director of Nursing VI. Lift Policy Acknowledgement Form signed by all staff upon implementation of Lifting Program for safety of staff and residents. Implementation of Skills checkoff list and quarterly in-services conducted by Equipment Company scheduled for a minimum of one year. [DATE]- All staff have received re-education; orientation process updated; monitoring conducted and documented with ongoing trainings continued.